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Debra K. Davenport
Auditor General
Performance Audit
Department of Economic
Security–Division of Children, Youth
and Families—Child Protective Services—
Timeliness and Thoroughness of Investigations
Performance Audit Division
DECEMBER • 2005
REPORT NO. CPS-0502
A REPORT
TO THE
ARIZONA LEGISLATURE
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting services
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Senator Robert Blendu, Chair Representative Laura Knaperek, Vice Chair
Senator Carolyn Allen Representative Tom Boone
Senator Gabrielle Giffords Representative Ted Downing
Senator John Huppenthal Representative Pete Rios
Senator Harry Mitchell Representative Steve Yarbrough
Senator Ken Bennett (ex-officio) Representative Jim Weiers (ex-officio)
Audit Staff
Melanie Chesney, Director and Contact person
Dot Reinhard, Manager
Catherine Dahlquist, Team Leader
Steven Montague
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 19, 2005
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Mr. David A. Berns, Director
Department of Economic Security
Transmitted herewith is a report of the Auditor General, A Performance Audit of the Department of
Economic Security, Division of Children, Youth and Families—Child Protective Services—Timeliness and
Thoroughness of Investigations. This audit was conducted under the authority vested in the Auditor
General by Arizona Revised Statutes §41-1966.
The report addresses the need for the Division to improve its investigations of child abuse and neglect
reports. Investigations are a critical first step to ensuring children’s safety and well-being. As such, it is
important that investigations be timely as any delay may further jeopardize the safety of the child.
Likewise, it is important that the investigation of the circumstances leading to the CPS report be thorough
so that the services and supports needed to ensure safety and well-being can be provided.
The report found that even though the Division is statutorily required to investigate all reports in a prompt
and thorough manner, some reports were not investigated, and many reports that were investigated did
not meet statutory or division requirements for timeliness and thoroughness. The Division believes that
unmanageable workloads, staff turnover, and the limited experience of some CPS supervisors and newly
hired investigators are the primary contributing factors to its investigation problems and continues to take
steps to address these issues. However, since these factors are likely to continue, additional meaningful
changes are needed, including streamlining the investigation process and establishing effective oversight
and accountability mechanisms.
As outlined in its response, the Department of Economic Security agrees with the finding and plans to
implement or implement in a different manner all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 20, 2005.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
Office of the Auditor General
TABLE OF CONTENTS
continued
1
9
9
10
12
16
18
19
24
a-i
a-iii
1
7
15
15
Introduction & Background
Finding 1: Investigations need to be improved
to better ensure children’s safety
Investigations help ensure children are safe
Division failed to investigate some CPS reports
Division has not conducted some investigations and other actions
in a timely manner
Some investigations not thorough
Investigation documentation not always current, accurate, or
complete
Additional actions needed to improve investigative performance
Recommendations
Appendix
Child Abuse Hotline Report Priority Classification System
Agency Response
Figures:
1 Child Abuse and Neglect Reports
Fiscal Years 2003 Through 2005
2 Number of Offices by District
Fiscal Year 2005
3 Compliance with Entering Allegation Findings
Within 21 Days of Report Receipt
Reports Received from July 1, 2002 Through March 31, 2005
4 Compliance with Closing or Transferring Investigations
Within 45 Days of Report Receipt
Reports Received from July 1, 2002 Through March 31, 2005
page i
State of Arizona
TABLE OF CONTENTS
Tables:
1 Summary of Child Abuse Report Priority Classification System
2 Child Abuse and Neglect Allegations
by Type and Priority
Fiscal Years 2003 Through 2005
3 Number of Children Removed
from Their Homes by the Department
April 1, 2001 Through March 31, 2005
4 Compliance with Initiating Investigations
Within Policy Time Frames
Reports Received from
July 1, 2002 Through March 31, 2005
3
4
6
13
concluded
page ii
The Office of the Auditor General has conducted a performance audit of Child
Protective Services’ (CPS) ability to respond to and investigate allegations of child
abuse and neglect in a timely and thorough manner. CPS is a program within the
Department of Economic Security’s (Department) Division of Children, Youth and
Families (Division). This audit was conducted under the authority vested in the
Auditor General by Arizona Revised Statutes §41-1966.
The Division’s CPS program is intended to
protect children by investigating allegations
of abuse and neglect while promoting the
well-being of children in permanent homes
and coordinating services to strengthen
families. In fiscal year 2005, the Division
received 37,545 reports alleging abuse or
neglect involving 47,638 children.1, 2 As
shown in Figure 1, the number of reports
received has increased by about 2,500
reports, or 7 percent, between fiscal years
2003 and 2005. During the same time
period, the number of reports requiring
investigation by CPS has increased by 27
percent, from 29,290 in fiscal year 2003 to
37,170 in fiscal year 2005.3 Some of this
increase is due to a legislative change that
requires all reports previously referred to the
Family Builders program to now be
investigated by CPS.4 The number of children
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Reports Received
Figure 1: Child Abuse and Neglect Reports
Fiscal Years 2003 Through 2005
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and June 30, 2005, maintained in the
Department's Children's Information Library and Data Source system.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
FY2003 FY2004 FY2005
Reports requiring CPS investigation Family Builders and other (tribal/military)
N=35,032
N=39,549 N=37,545
1 Auditor General staff calculation based on automated CPS case data for fiscal year 2005 provided by the Arizona
Department of Economic Security.
2 Children involved in one or more reports of abuse or neglect are counted only once.
3 The number of reports may vary slightly from those cited in division-prepared documents because of differences in the
dates the information is extracted from the automated case management system. Because the system is real-time
based, information is constantly being updated. The data auditors reported was extracted in July and August of 2005.
4 Prior to fiscal year 2005, CPS could refer certain low-risk and potential-risk child abuse reports to the Family Builders
program. At that time, the program was an alternative response system comprising a network of community-based
providers offering family-centered assessment, case management, and services. The reports referred to Family Builders,
which totaled 5,464 in fiscal year 2003 and 5,128 in fiscal year 2004, were not investigated by CPS. However, as of July
2004, all reports, unless falling outside the agency’s jurisdiction, must be investigated by CPS.
involved in CPS reports has grown 5.6 percent during the same time, which is in-line
with Arizona’s population growth of 5.2 percent.1
Investigations initiated by CPS reports
Reports of suspected child abuse are referred to CPS
through a state-wide, toll-free, 24-hour child abuse
hotline. Although anyone can report suspected abuse,
more than half the communications are made by people
who are mandated by law to report such instances, such
as law enforcement personnel, school personnel,
doctors, and other healthcare professionals. Centralized
hotline workers respond to all telephone and written
communications using a screening process to determine
whether the situation warrants an investigation. During
fiscal year 2005, the hotline received 111,539
communications, with 37,170 (33 percent) meeting the
criteria for a CPS investigation.2 In addition to
determining which communications require a CPS
investigation, hotline workers prioritize the reports, which
determines how quickly an investigation must be started.
As summarized in Table 1 (see page 3), the Division uses
four categories to prioritize investigations, with the
standard response time ranging from 2 hours for priority
1 reports, which are the most serious, to 7 days for
priority 4 reports, which are considered potential abuse
or neglect situations.3 (See Appendix, pages a-iii to a-iv,
for detailed information about the priority classification
system).
A CPS report may include more than one allegation.
Allegations are based on type of abuse and neglect, its severity, and the reported
victim. For example, the report may include an allegation of priority 1 physical abuse
for one child and priority 2 neglect for the same child and a sibling for a total of three
allegations. As noted in Table 2 (see page 4), the percentage of allegations by type
of abuse and neglect has remained stable across the past 3 years with neglect
State of Arizona
page 2
CPS Report Criteria
A communication meeting the criteria for investigation must
include:
􀁺􇩁 An allegation that a person under the age of 18 is the
subject of physical, sexual, or emotional abuse, neglect,
abandonment, or exploitation;
􀁺􇩁 A parent, guardian, or custodian has:
􀂍􈵩 inflicted,
􀂍􈵭 may inflict,
􀂍􈵰 permitted another person to inflict, or had reason to
know another person may inflict,
􀂍􈵯 or the alleged abusive person has not been identified
and the parent, guardian, or custodian has not been
ruled out as the person who inflicted, permitted
another person to inflict or had reason to know
another person would inflict abuse or neglect; and
􀁺􇩃 Contains sufficient information to locate the child.
Source: Department’s Child Abuse Hotline Procedures Manual.
1 Auditor General staff calculation of Arizona’s population and CPS report growth rates was based on U.S. Census Bureau
estimates for July 1, 2003, projections for July 1, 2005, and automated CPS case data for fiscal years 2003 through 2005
provided by the Arizona Department of Economic Security.
2 In addition to the communications requiring CPS investigation, the hotline received 357 communications requiring
investigation that fell within the jurisdiction of military and tribal governments and were referred to those jurisdictions.
3 The standard priority timeline for starting an investigation can be aggravated or mitigated by a hotline worker or CPS
supervisor based upon extenuating circumstances. For example, when a hospital worker makes a report to the hotline on
a newborn testing positive for exposure to an illegal substance, the report will be assigned a priority 1. However, the
response time of 2 hours may be mitigated by the hotline worker to 24 hours if the child is safe in the hospital and will not
be released for at least another day.
Office of the Auditor General
page 3
Table 1: Summary of Child Abuse Report Priority Classification System
Priority 1
High Risk
Response times:
Standard within 2 hrs
Mitigated within 24 hrs
Priority 2
Moderate Risk
Response times:
Aggravated within 24 hrs
Standard within 48 hrs
Mitigated within 72 hrs
Priority 3
Low Risk
Response times:
Aggravated within 48 hrs
Standard within 72 hrs
Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4
Potential Risk
Response times:
Aggravated within 72 hrs
(excluding weekends and
holidays)
Standard within 7 consecutive
days
Physical abuse:
Child death due to abuse,
neglect, or suspicious death;
severe or life threatening
injuries requiring emergency
medical treatment; and/or
parent presents severe
physical harm to the child
now.
Physical abuse:
Serious or multiple injuries
which may require medical
treatment, and/or a child is at
risk for serious physical abuse
if no intervention is received.
Physical abuse:
Injuries not requiring medical
treatment, and/or parent
threatens physical harm to
child if no intervention is
received.
Physical abuse:
Child at risk of physical injury
due to stressors in the home.
Neglect:
Severe or life-threatening
situations requiring
emergency intervention due
to the absence of a parent, or
a parent who is either unable
due to physical or mental
limitations or is unwilling to
provide minimally adequate
care.
Neglect:
Serious or non-life-threatening
situations requiring intervention
due to the absence of a parent,
or a parent who is either
unable due to physical or
mental limitations or is
unwilling to provide minimally
adequate care.
Neglect:
Situations which may require
intervention due to the
absence of a parent, or a
parent who is either unable
due to physical or mental
limitations or is unwilling to
provide minimally adequate
care, which includes
exploitation of a child.
Neglect:
Child at risk of neglect due to
stressors in the home.
Sexual abuse:
Physical evidence of sexual
abuse reported by a medical
doctor or child reporting
sexual abuse within the past 7
days.
Sexual abuse:
Sexual behavior or attempted
sexual behavior occurring 8
days or up to one year ago,
and/or child is exhibiting
indicators consistent with
sexual abuse.
Sexual abuse:
Sexual behavior or attempted
sexual behavior occurring
beyond one year and
perpetrator currently has
access to a child.
Sexual abuse:
NA
Emotional abuse:
NA
Emotional abuse:
Child diagnosed by a mental
health professional as
exhibiting symptoms of
emotional abuse caused by a
parent.
Emotional abuse:
Parent demonstrates
behavior which may result in
emotional trauma to a child.
Emotional abuse:
NA
Source: Department’s Child Abuse Hotline Procedures Manual.
State of Arizona
page 4
Table 2: Child Abuse and Neglect Allegations
by Type and Priority
Fiscal Years 2003 Through 2005
Fiscal Years
2003 2004 2005
Number
of
Allegations
Percentage
of
Total Allegations
Number
of
Allegations
Percentage
of
Total Allegations
Number
of
Allegations
Percentage
of
Total Allegations
Physical Abuse
Priority 1 641 1% 786 1% 689 1%
Priority 2 3,496 5 3,999 5 3,811 5
Priority 3 7,119 11 8,139 11 8,736 11
Priority 4 4,862 8 5,425 7 6,228 8
Subtotal 16,118 25 18,349 24 19,464 25
Sexual Abuse
Priority 1 292 <1 355 <1 383 <1
Priority 2 2,036 3 2,377 3 2,224 3
Priority 3 1,323 2 1,409 2 1,340 2
Priority 4 NA 1 NA NA
Subtotal 3,651 5 4,141 5 3,947 5
Emotional Abuse
Priority 1 NA NA NA
Priority 2 129 <1 182 <1 142 <1
Priority 3 1,253 2 1,601 2 1,422 2
Priority 4 NA NA NA
Subtotal 1,382 2 1,783 2 1,564 2
Neglect
Priority 1 7,193 11 9,288 12 9,101 11
Priority 2 10,647 17 13,510 18 12,633 16
Priority 3 17,365 27 20,191 27 22,826 28
Priority 4 8,164 13 8,950 12 10,699 13
Subtotal 43,369 68 51,939 69 55,259 68
Death by Abuse
Priority 1 22 <1 53 <1 42 <1
Death by Neglect
Priority 1 22 <1 24 <1 35 <1
Total allegations in CPS
reports requiring
investigations
64,564
100%
76,289
100%
80,311
100%
1 NA indicates the category has no priority classification.
Source: Auditor General staff analysis of CPS data maintained in the Department’s Children’s Information Library and Data Source system.
Office of the Auditor General
page 5
allegations comprising approximately two-thirds of total annual allegations. Similarly,
the distribution of allegations by priority has also remained relatively stable over the
years, with priority 1 allegations typically comprising the smallest percentage and
priority 3 allegations typically comprising the largest percentage.
When it is determined that a CPS investigation is
necessary, an investigative case manager will
complete activities such as interviewing the alleged
victim(s), perpetrator(s), and other knowledgeable
sources to help assess the risk of harm to the child or
children involved and evaluate the conditions that
support or refute the alleged abuse or neglect. Statute
requires that a finding be documented on each
allegation within 21 days of the CPS report being
made. Potential findings include “proposed
substantiated,” “unsubstantiated,” or “unable to
locate.”
Based on the investigation, the Division may take one
or more of the following actions:1
􀁺􇨠 Close the case—When the Division determines
there are no risk factors severe enough to warrant
ongoing involvement to ensure the children’s
safety, the Division may close the case after
investigation without providing further services. Alternately, a case may be
closed if the family refuses offered services and the risks to the child’s safety
are not severe enough to warrant legal action. The Department’s automated
CPS data indicates that 18,615, or 50 percent, of CPS reports received in fiscal
year 2005 were closed after investigation without the family receiving services.2
􀁺􇩐 Provide short-term services—When the Division determines that a child is at risk
for maltreatment, it may offer the family services such as counseling and parent
skills training that could allow the child to live safely at home. These services,
referred to as in-home services, may be provided directly by department staff,
by contract, or through referral to community agencies. The services are
typically provided for several weeks to several months, and the families
participate in them voluntarily. The Department’s automated CPS data indicates
that the families who were associated with 14,416, or 39 percent of CPS reports
received in fiscal year 2005, were provided with in-home services.
Criteria for Allegation Findings
􀁺􇩐 Proposed substantiated is used when there is
probable cause, i.e., facts that provide reasonable
grounds to believe the alleged abuse or neglect
occurred.
􀁺􇩕 Unsubstantiated is used when there is not probable
cause to believe the alleged abuse or neglect
occurred.
􀁺􇩕 Unable to locate is used when the child victim cannot
be located and there is insufficient evident to
conclude that the child was abused or neglected
without interviewing or observing the child.
Source: Department’s Children’s Services Manual.
1 The number of actions cited in the following bullets is based on the information recorded in the Division’s automated
case management system as of August 9 and 10, 2005.
2 Although families may not have received services paid for through the Department, they still may have been referred to
community services. However, the Division does not currently have a mechanism for tracking this information.
􀁺􇩆 File an in-home dependency or in-home intervention dependency—When the
Division determines that a child is currently safe but is at high risk of harm, and
safeguards can be established to maintain the child’s continued safety and well-being
in his or her home, CPS may file an in-home dependency or an in-home
intervention dependency with the local juvenile court. An in-home dependency
petition, if approved by the court, makes the child a ward of the court and places
the child in the physical custody of his/her parent(s). Under an in-home
intervention dependency, the child is allowed to stay in his or her home when
short-term intervention—up to 1 year—appears likely to resolve risk issues and
the parent, guardian, or custodian agrees to a case plan and participation in
services. The child does not become a ward of the court. However, if the parent,
guardian, or custodian fails to comply with the case plan, the court may take
whatever steps it deems necessary to obtain compliance or may award custody
of the child to the State, at which time the child may be placed in out-of-home
care. According to the Attorney General’s Office, between January 1, 2004 and
November 15, 2005, there were 360 in-home dependency petitions filed. In
addition, there were 39 in-home intervention dependency petitions
filed between January 1, 2004 and November 10, 2005.
􀁺􇩆 File an out-of-home dependency—When the Division
determines that a child is in imminent danger of abuse or
neglect, he or she may be removed from the home and
temporarily placed in an approved foster care setting, such
as with a relative or in a licensed foster or group home.1
When this happens, the Division must either file a
dependency petition with the local juvenile court within 72
hours or return the child to his or her family. If the court
determines the child to be dependent, it will award custody to
the State, and the child will remain in an out-of-home
placement until the parent(s) address(es) the risk factors that
prevent him and/or her from caring for the child safely at
home. According to a department report, the number of
children removed from their homes semiannually has
increased by more than 50 percent between April 2001 and
March 2005, with the greatest increases occurring between
October 2002 and September 2003, as illustrated in Table 3.
State of Arizona
page 6
Table 3: Number of Children Removed
from Their Homes by the Department
April 1, 2001 Through March 31, 2005
Reporting period
Number
of children
removed
Semiannual
percent change
Apr 2001 – Sept 2001 2,387 NA
Oct 2001 – Mar 2002 2,501 5%
Apr 2002 – Sept 2002 2,655 6%
Oct 2002 – Mar 2003 2,961 12%
Apr 2003 – Sept 2003 3,349 13%
Oct 2003 – Mar 2004 3,504 5%
Apr 2004 – Sept 2004 3,630 4%
Oct 2004 – Mar 2005 3,617 0%
Source: Child Welfare Reporting Requirements Semi-annual
Report prepared by the Arizona Department of Economic
Security, Division of Children, Youth and Families,
Administration for Children, Youth and Families.
1 When CPS removes a child from his or her home, the Department is required to conduct a Removal Review Team
conference within 72 hours of the child’s removal. The purpose of this conference is to determine whether the removal
was necessary, if there are alternatives to continued out-of-home placement, or if continued out-of-home placement is
necessary and, therefore, an out-of-home dependency petition must be filed. Per A.R.S. §8-822, the Removal Review
Team consists, at a minimum, of a CPS case manager and his or her supervisor, two members of the Foster Care Review
Board, and the child’s physician if the child has a medical need or chronic illness. If all reasonable efforts to reach the
child’s physician have been made and the physician is not available, the team shall include a licensed physician who is
familiar with children’s healthcare. Other qualified individuals such as a counselor or therapist may also be included in the
review.
Organization, staffing, and budget
The CPS program provides child welfare services
throughout the State. In order to accomplish this, CPS
is organized into 68 offices within 6 regional districts
(see Figure 2).1 These offices are composed of one or
more units typically consisting of a supervisor, 5 to 7
case managers, a case aide, and a secretary. In
Districts I and II, the two urban districts, unit function is
generally specialized. For example, case managers in
one unit may handle only CPS investigations, while
another unit may handle only ongoing services cases.
In the 4 rural districts, the case managers in a single
unit may be required to perform both investigations
and ongoing case management. However, according
to division management, each unit has at least one
case manager dedicated to conducting CPS
investigations.
The majority of the Division’s employees work within
the CPS program. The remaining employees provide
administrative and support services to the Division.
According to the Department, in fiscal year 2005, the
Division had 1,793 full-time equivalent (FTE) positions,
of which 871 were CPS specialists (i.e., case
managers) and 152 were CPS supervisors.2 In addition, there were another 4 FTEs
classified as human service specialists who also manage CPS cases.
To provide CPS services, the Division receives both state and federal funding.
Although the Division does not track expenditures by functional area, the Division
estimates that it expended approximately $23 million on salaries and benefits for
investigative and hotline staff in fiscal year 2005.3 Part of the expenditure was for a
stipend intended to help in the recruitment and retention of investigators that was
Office of the Auditor General
page 7
District IV
8 Offices
District I
19 Offices
District II
10 Offices
District III
12 Offices
District V
9 Offices
District VI
10 Offices
Figure 2: Number of Offices by District
Fiscal Year 2005
Source: Auditor General staff analysis of the Division of Children, Youth and Families’
Directory of Child Protective Services Offices.
1 In addition to the 68 CPS offices, the Division has case management staff assigned to 7 non-DES locations, such as the
Mesa Center Against Family Violence.
2 The numbers of CPS specialist and supervisor FTEs include 42 CPS specialists and 7 supervisors who work at the
hotline, and exclude 47 CPS specialist FTE positions assigned for trainees. The Division’s positions are funded by
General Fund and Temporary Assistance for Needy Families (TANF) program appropriations and other nonappropriated
federal program monies.
3 The Division estimated its investigative staff salary and benefit expenditures using the federally approved Arizona
Random Moment Sample (RMS) time study methodology. This methodology measures the work effort of the entire group
of eligible staff involved in the CPS program by sampling and analyzing the work efforts of a cross-section of the group.
RMS methods employ a technique of polling employees at random moments over a given time period to determine the
nature of the employee’s work activities and tallying the results of the polling. The method provides a statistically valid
means of determining what portion of the selected group of staff’s workload is spent performing activities that are
reimbursable by the federal government to allocate the labor costs of direct service staff to appropriate federal and state
funding sources.
authorized during the 2003 Second Special Session.1 The stipend equals 10 percent
of a worker’s base salary and is paid on a monthly basis to those investigators with
at least 36 months of CPS experience who are assigned 6 or more CPS reports to
investigate in the same month the reports are received. These reports are in addition
to any existing cases already being worked by the investigator. The Division reports
that it expended $538,000 on the investigative stipend in fiscal year 2005.
1 Legislation passed during the 2003 Second Special Session did not authorize any additional monies to the Department
for the stipend.
State of Arizona
page 8
Investigations need to be improved to better
ensure children’s safety
To better ensure children’s safety, the Division needs to improve its investigations of
child abuse and neglect reports. Investigations are a critical first step to ensuring
children’s safety and well-being. However, even though the Division is statutorily
required to investigate all reports, some reports were not investigated, and many
reports that were investigated did not meet statutory or division requirements for
timeliness and thoroughness. The Division believes that unmanageable workloads,
staff turnover, and the limited experience of some CPS supervisors and newly hired
investigators are the primary contributing factors to its investigation problems and
continues to take steps to address these issues. However, since these factors are
likely to continue, additional meaningful changes are needed, including streamlining
the investigation process and establishing effective oversight and accountability
mechanisms.
Investigations help ensure children are safe
Investigating child abuse and neglect reports is a critical first step for ensuring
children’s immediate safety and long-term well-being. As such, it is important that
investigations be timely as any delay may further jeopardize the child’s safety.
Likewise, it is important that the investigation of the circumstances leading to the CPS
report be thorough so that the services and supports needed to ensure safety and
well-being can be provided. In addition to the immediate safety issue, there may be
potential long-term consequences for children left in situations where they may be
abused or neglected. According to a report from the National Clearinghouse on Child
Abuse and Neglect Information, studies have found that abuse and neglect can have
long-term physical, emotional, and behavioral consequences.1 For example, shaking
a baby (a form of physical abuse) may result in blindness, learning disabilities, mental
retardation, or paralysis. Further, it is important that the information obtained during
an investigation is documented in a timely manner in the automated case
Office of the Auditor General
FINDING 1
page 9
1 National Clearinghouse on Child Abuse and Neglect Information. Long-term Consequences of Child Abuse and Neglect.
Washington, D.C. (July 2005).
management system so that it is readily available to other CPS staff and
management who may need it, such as after-hours staff responding to a subsequent
report or supervisors monitoring workload and productivity.
Division failed to investigate some CPS reports
The Division has not investigated some of the CPS reports it has received. Further,
auditors identified some additional reports for which it is unclear whether
investigations were conducted or thoroughly completed. Despite this, the Division
has been reporting to the Legislature that is has investigated 100 percent of the
reports requiring investigation.
Some CPS reports have not been investigated—Despite a statutory
requirement to investigate 100 percent of the CPS reports it receives and the
importance of doing so to protect children, the Division has failed to investigate some
of the reports it received between July 2002 and March 2005. Auditors’ analysis of
the automated case data for the 91,267 CPS reports received during this period
found that 920 of these reports were missing both the date the investigator
responded to the report as well as the investigation’s results, known as allegation
findings, which raised questions about whether these reports had been investigated.
Statute requires that allegation findings be entered in the Division’s automated case
management system within 21 days of receiving the report. Further, division policy
requires that all documentation on the investigation, including the initial investigation
response date, be completed within 45 days of the investigator’s receiving the report.
Auditors examined the complete case records for a judgmental sample of 15 of the
920 reports and found that 3 had not been investigated by CPS.1 Specifically:
􀁺􇨠 CPS received a report in November 2003 alleging priority 2 sexual abuse of the
alleged perpetrator’s 10-year-old daughter, but there was no evidence of an
investigation occurring.
􀁺􇩃 CPS received a report in June 2004 alleging priority 2 physical abuse of a child
under the age of 2, but there was no evidence of an investigation occurring.
􀁺􇩃 CPS received a report in October 2004 alleging priority 3 physical abuse of a 7-
year-old child, but there was no evidence of an investigation occurring.
Division management has since directed CPS staff to review the remaining reports to
determine whether any additional reports were not investigated. Although the
Division reports that it has completed this review, auditors found problems and
inconsistencies with the review’s conclusions and therefore it cannot be reliably
1 A case record comprises an electronic and hard copy record. The electronic record is maintained in the Division’s
automated case management system and includes information on the Division’s investigative activities, findings, and
decisions. The hard copy record includes documents generated outside the Division, documents that require signatures
from individuals outside the Division, and hard copy forms not maintained electronically.
State of Arizona
page 10
determined how many of these 920 reports were or were not investigated. While the
Division found evidence that some of these reports were investigated, in other
instances the investigations had only occurred within the past few months even
though the reports had been received months or even years earlier. Further, in other
instances, even though the Division indicates that the reports were investigated by
CPS, the case records do not support this assertion. For example:
􀁺􇩉 In July 2004, a law enforcement officer reported to the hotline allegations of
priority 4 neglect involving 2 children. In November 2004, 3-1/2 months after the
report was received, it was assigned to a CPS investigator. However, the
automated case management system does not contain any information
regarding an investigation by CPS. In fact, the only other information in the
system shows that in September 2005, 14 months after the report was received,
finding allegations were entered in the system but they appear to be
placeholders because there is a comment related to the allegation findings that
says “investigation continuing—determination is still being made as to findings.”
Unclear whether other investigations were conducted or thoroughly
completed—For some additional CPS reports, it is unclear whether investigations
were conducted or thoroughly completed because important information is missing
from the automated case management system. For example, auditors’ analysis of
the automated case data for the 91,267 CPS reports received between July 2002 and
March 2005 found another 651 reports that had an initial investigation response date
recorded in the automated case management system, but were still missing any
allegation findings as of July 21, 2005. The recording of allegation findings signifies
that the investigation has been completed and it documents the investigator’s
conclusions. In addition, there were another 76 reports that had allegation findings
recorded in the system for some, but not all, of the allegations. In both examples,
many of the reports were received in fiscal years 2003 and 2004. Auditors also noted
entries in the electronic case records of a few reports where division staff questioned
or could not determine whether there had been an investigation because there was
no information in either the hard copy records or the automated system regarding
what occurred during the investigation.
Division inaccurately reports 100 percent investigation rate—Although
auditors found instances where CPS reports were not investigated and lack of
documentation in the system to support whether other investigations were
conducted or thoroughly completed, the Division has routinely reported in its Child
Welfare Reporting Requirements Semi-annual Report that it has investigated 100
percent of the reports requiring a CPS investigation. The semiannual reports further
note that the Division has maintained this investigation rate since 1998. However, this
rate is based on whether a report is assigned for investigation, not on whether it has
actually been investigated. A more appropriate measure of investigation rate would
be based on the number of CPS reports received that have findings for all allegations
and for which the supervisor has reviewed and approved the findings. This would
Office of the Auditor General
page 11
require a modification to the automated case management system to capture
supervisor approval of each of the allegation findings.
Division has not conducted some investigations and
other actions in a timely manner
Although the Division is statutorily required to conduct prompt investigations, staff
have not consistently met statutory and policy time frames for initiating investigations,
conducting the investigative work, documenting investigative results or allegation
findings, and closing or transferring investigations for ongoing case management. It
is important that these actions occur in a timely manner to ensure the safety of
children, as well as to initiate additional reviews, ensure information is available if a
subsequent report is received on the same family, and for management to monitor
staff workload and productivity.
Division has not initiated some investigations in a timely manner and
does not know when other investigations began—Although the
Department is statutorily required to conduct prompt investigations of child abuse
and neglect to ensure the children’s safety and well-being, it has not initiated some
investigations in a timely manner and does not know when it began some other
investigations. Division policy outlines the time frames within which an investigator
must begin investigating a CPS report. For example, if the report has been classified
as priority 1, the investigator has 2 hours from the time the report is transmitted from
the hotline to the local office to initiate action to determine the safety of the children
involved. Auditors’ analysis of the automated case data for the 91,267 CPS reports
received between July 2002 and March 2005 found that only 49,197, or 54 percent,
had investigations initiated within the outlined time frames; 11,363, or 12 percent,
were not initiated within the outlined time frames; and 30,707, or 34 percent, had
missing or invalid investigation response dates, making it impossible to tell if the
investigations were initiated in a timely manner. As illustrated in Table 4 (see page 13),
of the investigations that were not initiated on time, most were initiated in 5 or fewer
days, but 1,253 investigations, or 11 percent, were started more than 30 days late.
Most of the reports with missing and invalid response dates—approximately
25,000—were due to invalid response dates. Invalid response dates arise when the
response date precedes the date the report was assigned for investigation.
According to division staff, invalid dates may be a result of typographical errors;
recording the date emergency personnel, such as the police, responded to the
situation (rather than the CPS investigator); or the Division’s practice of not recording
in the automated case management system the assignment of a report for
investigation when the family surname is unknown until the investigator has identified
the family. In order for the Division to effectively monitor investigative timeliness, it will
need to address these issues through adding edits to the automated system to
prevent invalid dates being input, clarifying policy to clearly indicate that the CPS
State of Arizona
page 12
investigator’s response time must be recorded in the automated case management
system even if emergency personnel are also involved, and modifying the automated
case management system to allow the recording of a report assignment with an
unknown family surname and then later merge it with any prior cases once the family
surname becomes known.
Division has not always conducted investigation work promptly—Not
only is it important that investigations be initiated in a timely manner, it is also
important that all of the needed investigative work be conducted promptly to ensure
children’s safety and ensure that needed services are provided in a timely manner.
Statute requires that an investigation be completed within 21 days of a report's
receipt. However, auditors noted that the investigations for some of the 920 reports
discussed earlier languished for months or even years after the report was received.
For example:
􀁺􇩉 In January 2003, CPS received a report alleging priority 3 physical abuse of a 5-
year-old child by his father. The report was assigned to an investigator who
initiated an investigation in February 2003 by attempting to contact the child at
school and the family at their home twice during a 10-day period. During both
attempted home visits, the investigator reported knocking on the door several
Office of the Auditor General
page 13
Table 4: Compliance with Initiating Investigations
Within Policy Time Frames
Reports Received from
July 1, 2002 Through March 31, 2005
Total
Priority 1
High Risk
Priority 2
Moderate Risk
Priority 3
Low Risk
Priority 4
Potential Risk
Number of investigations
initiated within policy time
frames
49,197
5,382
14,571
20,952
8,292
Number of investigations
with missing or invalid
response dates
30,707
10,265
9,138
8,796
2,508
Number of investigations
not initiated within policy
time frames1
Delayed 1 day or less 3,185 547 964 1,422 252
Delayed 2 to 5 days 4,185 236 1,389 2,274 286
Delayed 6 to 10 days 1,303 57 387 672 187
Delayed 11 to 20 days 1,018 24 308 554 132
Delayed 21 to 30 days 419 8 136 214 61
Delayed over 30 days 1,253 46 356 657 194
Total 11,363 918 3,540 5,793 1,112
1 The timeliness analysis of initiating report investigations takes into account aggravated and mitigated time frames.
Source: Auditor General staff analysis of data on CPS reports received between July 1, 2002 and March 31, 2005,
maintained on the Department’s Children’s Information Library and Data Source system.
times and leaving her business card. However, no additional investigative work
was performed until September 2005, more than 2-and-1/2 years after the report
was received, when the same investigator contacted several schools and found
out where the child was now attending school. The investigator obtained the
family’s address from the school and conducted a home visit. During the home
visit interview, the parents denied the allegations. A week later, the investigator
interviewed the alleged child victim and his brother at school. Both of them
denied the incident. The investigator subsequently unsubstantiated the
allegation, citing “No evidence of physical abuse or neglect was found to
request proposed to substantiate.”
􀁺􇩏 On January 14 and January 19, 2005, two separate reports were received on the
same family alleging priority 3 physical abuse and priority 2 sexual abuse of the
alleged perpetrators’ 11-year-old adopted daughter. However, no investigative
activities were performed until July 2005, 6 months later, when a CPS unit
supervisor discovered that these reports had never been investigated. The
assigned investigator telephoned the adoptive father and set up an appointment
for a home visit. However, on the date of the scheduled visit, no one was home.
The visit was rescheduled for 2 weeks later, at which time the investigator went
to the home and interviewed the father and child. The investigator
unsubstantiated the allegations the next day, citing “Child was seen and
interviewed on 8/2/05. Child did not disclose abuse or neglect. There is no
evidence to support a substantiated finding. Child appeared healthy and
developmentally on target.”
Division has not always recorded investigation results in a timely
manner—Although investigators are statutorily required to record the investigation
results or allegation findings in the automated case management system within 21
days of receiving a report, investigators have frequently failed to do so. Recording the
allegation findings is important because it indicates that the investigation has been
completed.
It is also important that the allegation findings be entered into the system in a timely
manner for a number of other reasons. First, if an allegation is proposed for
substantiation, it is referred to the Protective Services Review Team within CPS, which
reviews the investigation to ensure it was thorough and the evidence supports the
proposed substantiation. Second, if it is determined that an allegation was
unsubstantiated, CPS must inform the child’s parent(s) or guardian(s) of the
investigation’s outcome if he/she either made the report or was the alleged
perpetrator. Third, if a subsequent CPS report is made on the family or the alleged
perpetrator, the investigator will be able to factor the allegation findings into the
subsequent report. Finally, recording allegation findings allows CPS management to
monitor investigator workload and productivity.
State of Arizona
page 14
However, auditors’ analysis found less than one-half
of the allegation findings were entered into the
system on time. Auditors analyzed the automated
case data for the 193,702 allegations included in
CPS reports received between July 2002 and
March 2005 and found that as of July 21, 2005, a
total of 92,165, or 48 percent, of the allegation
findings were entered into the automated case
management system on time (see Figure 3). Of the
101,537 allegation findings that were not entered
into the system on time, 45,530, or 45 percent, of
the allegation findings were entered a month or
more after the required time frame, and 3,441, or 3
percent, of the allegations were still missing
findings. Therefore, it was not readily apparent
whether those investigations have been
completed.
Division has not always closed or
transferred investigations in a timely
manner—Although division policy requires that
within 45 days of a report’s receipt the investigator
is to either close the case in the system or transfer
it for ongoing case management, investigators
have frequently failed to do so. It is important that
investigations be closed or transferred in a timely
manner because these actions ensure that the
investigation undergoes supervisory review to
make sure it is thorough and complete and that
children and families are promptly receiving any
needed services. Further, failure to close or
transfer investigations in a timely manner results in
an inaccurate picture of the number of active
investigations and hinders management’s ability
to monitor and manage investigator workload and
productivity. However, auditors’ analysis found
that less than one-half of the investigations
initiated from reports received between July 2002
and March 2005 were closed or transferred on
time. As noted in Figure 4, as of July 21, 2005,
37,609, or 41 percent, of the investigations were
closed or transferred on time while 7,368, or 8
percent, were closed or transferred 6 months or
more after the required time frame; and 7,346, or
8 percent, of the investigations still had not been
closed or transferred.
Office of the Auditor General
page 15
Figure 3: Compliance with Entering Allegation Findings
Within 21 Days of Report Receipt
Reports Received from July 1, 2002
Through March 31, 2005
Exceeded by 1
to 7 days—20,993
Exceeded by 8 to
30 days—31,573
Exceeded by 1 to
6 months—38,706
Met
standard—92,165
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and March 31, 2005, maintained on the
Department's Children's Information Library and Data Source system.
Exceeded by over
Exceeded by 6 months 1 year—1,667
to 1 year—5,157 Not entered—3,441
Figure 4: Compliance with Closing or
Transferring Investigations
Within 45 Days of Report Receipt
Reports Received from July 1, 2002
Through March 31, 2005
Exceeded by 6 months
to 1 year—5,202
Not closed—7,346
Exceeded by 1 to
30 days—14,723
Exceeded by 1
to 6 months—24,221
Met
standard—37,609
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and March 31, 2005, maintained on the
Department's Children's Information Library and Data Source
system.
Exceeded by
over 1 year—2,166
Some investigations not thorough
Although the Division is statutorily required to conduct thorough investigations to
ensure child safety and it has developed policies to help ensure staff meet this
requirement, the Division has not ensured adherence to the policies. Auditors
randomly selected and reviewed the hard copy and electronic records for 30 of the
18,839 CPS reports received between October 1, 2004 and March 31, 2005, and
found four key areas where staff have not consistently followed policies to ensure
thorough investigations. Specifically:
􀁺􇨠 Independent supervisory review of prior reports not always occurring—Although
required by policy, investigators have not always obtained an independent
supervisory review of new CPS reports when three or more prior reports existed.
The intent of this review by supervisory personnel unconnected to the case is to
determine, among other things, whether all allegations in previous reports were
addressed; whether a pattern of cumulative harm to the identified child victim or
any other child residing in the home is evident or emerging; and whether
additional information, such as school records or mental health records, should
be obtained. Eleven of the 30 reports auditors reviewed met the criteria for an
independent review because each had between 3 and 12 prior reports.
However, there was no evidence that an independent review had occurred for
any of these reports. One of the reports that should have undergone an
independent review had 5 prior substantiated reports comprising 25 allegations
of neglect and abuse ranging from priority 1 to priority 4.
􀁺􇨠 Reasonable efforts to locate and contact the child victim and his/her family not
consistently occurring—Although division policy requires investigators to make
reasonable efforts to locate and contact the alleged child victim and his or her
family to ensure the child is safe and assess whether services are needed to
ensure the child’s continued safety, auditors’ review noted 10 instances where
investigative efforts did not appear adequate. The case example in the textbox
(see page 17) illustrates a situation in which insufficient action was taken to
contact the child victims, and as a result, needed services were unnecessarily
delayed.
􀁺􇩃 Child safety assessments not consistently completed or approved as
required—Investigative staff have not always completed a child safety
assessment at the conclusion of an investigation, and even when they were
completed, supervisors had not always reviewed and approved these
documents. Division policy requires that a child safety assessment (CSA) be
conducted as part of every investigation to assess the present and/or
foreseeable danger of serious harm to children in the family and, if appropriate,
State of Arizona
page 16
to develop a safety plan.1 Investigators are required to complete a CSA within
24 hours after first seeing the alleged child victim and at the conclusion of the
investigation; however, auditors found that for 13 of the 30 investigations, there
was no evidence that a CSA was completed at the conclusion of the
investigation, nor any indication why the assessment had not been completed.
Policy also requires supervisors to sign and date the completed hard copy CSA
to indicate their review and approval of the overall assessment and safety plan.
However, auditors found that for 9 of the 30 investigations, supervisors had not
signed and dated the CSA.
􀁺􇩉 Information recorded on system does not consistently reflect investigation
findings—Despite division policy that outlines the criteria for allegation findings,
auditors’ review of 30 hard copy investigative files and associated electronic
case records noted instances where the allegation findings entered into the
automated case management system did not accurately reflect the outcome of
the investigation. For example, in the case example cited above, even though
the three reports appear to validate the allegations of neglect of the younger
child and were proposed for substantiation by the investigator in consultation
with her acting supervisor, they were subsequently modified to unsubstantiated
by another supervisor with no explanation. In another example, the investigator
unsubstantiated priority 2 neglect allegations involving two children even though
she never made contact with the children. The supervisor assigned to the
investigation later told auditors that the findings should have been recorded as
“unable to locate.”
Office of the Auditor General
page 17
Case Example
In March 2005, a CPS report was received citing priority 2 allegations of neglect involving two
children, ages 10 and 17. Although the family had received two prior reports alleging similar
allegations in October and December of 2004, there was no evidence that the case manager who
was assigned to the two prior reports ever contacted the children or did other important investigative
tasks. A month after the second report was received, another case manager was asked to assist the
assigned case manager with the investigation; however, the Division did not ensure that the family
and the victims were contacted. Specifically, the assisting case manager attempted but was unable
to visit the family at its home. Although the assisting case manager was informed by the mother
that he should visit the children at school, he was unavailable to assist with the investigation during
school hours. Further, although the assisting case manager informed the supervisor of this
situation, she did not assign someone else to interview the children. Therefore, it was not until the
third report was received in March 2005 and a different case manager was assigned that a thorough
investigation took place. As a result, the youngest child was removed from his home so that he
could receive medical and clinical treatment for several serious mental health disorders.
Additionally, the following services were provided to the family: out-of-home placement for the
youngest child, psychological evaluations for the youngest child and mother, and parent aide
services and substance abuse treatment for the mother.
1 When conducting a CSA, investigators determine the potential for present or foreseeable danger of serious harm to a child
through assessment of 17 safety factors, such as whether sexual abuse is suspected and whether circumstances suggest
that continued sexual abuse is an immediate concern, or whether drug and/or alcohol use by the caregiver or others living
in or having access to the home places the child in immediate danger.
Investigation documentation not always current, accurate,
or complete
Although division policy requires that the case records be current, accurate, and
complete, auditors identified problems in each of these areas. First and foremost, the
case record information is crucial in assessing and ensuring child safety. It is also
important for other critical functions, such as for after-hours and other staff
addressing urgent situations when the assigned investigator is not available and for
the safety assessment and decision-making process if a subsequent report on a
family is received. Because the appropriateness of decisions made using case data
is contingent on the data’s quality, inaccurate or incomplete information may lead to
poor or dangerous decisions. In addition, current, accurate, and complete case
records are needed for management to adequately monitor staff workload and
productivity.
Despite the importance of documentation, previous audits as well as this one have
identified problems with the case record documentation. For example, a May 2005
performance audit of the Division’s data integrity process found that there were errors
and omissions in the automated system’s data, and 48 percent of the case
management staff responding to an auditor survey reported that data problems
hindered their ability to efficiently and effectively perform their job duties. Further, 13
percent of the case management staff responding to the survey reported that data
problems hindered their ability to ensure child safety and well-being (see Auditor
General Report No. CPS-0501). The Division agreed with this finding and plans to
implement all recommendations. Additionally, although policy requires the electronic
case record to be updated no more than 10 days from the date of the event being
documented, this audit found examples where investigative information was not
recorded until months or even years after the investigation was conducted,
sometimes with questionable accuracy. For example:
􀁺􇨠 In August 2005, 2-and-1/2 years after an initial CPS report was made, a former
CPS supervisor entered information into the system indicating that an
investigation was conducted 2 months after the report was received and that the
alleged physical abuse of the 6-month-old by his father was unsubstantiated
because no bruising was evident. Further, the mother indicated the father had
returned to Texas and she was going to raise the child on her own away from
the father’s violent behavior. According to the supervisor, during this audit she
obtained this information by telephone from the CPS investigator whom this
report had been assigned to (this individual had not worked for the Department
for over 2 years). However, the accuracy of this information is questionable
because the date of the case manager’s visit to the child is recorded in the
system as taking place 2 months after the case manager resigned from the
Department. Auditors subsequently spoke with the former CPS investigator, and
the information he provided leads auditors to further question the accuracy of
the information in the system. Specifically, the former CPS investigator provided
auditors with information that conflicts with the information the supervisor
State of Arizona
page 18
recorded in the case management system. For example, he reported to auditors
that he interviewed the father, but the information in the system noted that the
father had moved to another state and only the mother was interviewed.
Further, in some instances the case record documentation is not complete. For
example, although policy requires at the close of an investigation that the investigator
document a case note narrative in the Division’s automated case management
system that summarizes the progress, events, concerns, and crucial information
related to the investigation, auditors found many examples where this did not occur.
One example involved allegations of neglect and physical abuse of two children
where the family had an ongoing history of alleged abuse and neglect. The closing
summary indicated only that “the case was staffed with a supervisor to discuss the
allegations, it was determined the allegations would be unsubstantiated, and the
case would be approved for closure.” There was no mention of the prior case history,
the basis for the unsubstantiated findings, or whether services had been offered to
and accepted by the family. If prepared properly, closing summaries can be used by
subsequent workers to quickly obtain a comprehensive picture of what occurred
during prior investigations without having to read the entire case record. Therefore,
the Division needs to ensure that investigators include in their investigative
documentation a comprehensive closing summary. One way to improve
documentation may be for the Division to adopt, for state-wide use, the closing
summary template used in districts 3 and 4. The template guides investigators and
ongoing case managers to document information such as the original reason for
service, present whereabouts of the children, progress made in
services/achievement of goals and objectives, justification for case closure, areas
where problems may recur, description of aftercare plan and services, case
manager's assessments of the family, and date and description of the last face-to-face
contact.
Additional actions needed to improve investigative
performance
The Division needs to take additional steps to improve its investigative performance.
The Division attributes its investigation problems primarily to unmanageable
workloads, staff turnover, and the limited experience of some CPS supervisors and
newly hired investigators and continues to address these issues. However, since
these factors are likely to continue, additional meaningful changes are needed,
including streamlining the investigation process and establishing effective oversight
and accountability mechanisms.
Division taking steps to address ongoing barriers hindering
investigative performance—Division personnel attribute many of the
investigation problems to unmanageable workloads, staff turnover, and the limited
experience of some CPS supervisors and newly hired investigators. Between 2002
and 2006, in an effort to ensure manageable workloads, the Division has increased
Office of the Auditor General
page 19
the number of its CPS case management and support staff positions by 551.1
However, according to division management, this has not resolved the workload
issue because of continuing problems with hiring and retaining staff. The Division
reports that as of June 2005, it had 165 case manager positions vacant and an
annualized turnover rate of 19.8 percent.2 Although it also had 163 staff in training to
fill the vacant positions, the program administrator indicated that due to the
complexity of the job, it takes staff a year or more to become experienced and
competent in their jobs, which impacts their ability to manage their workloads. The
quality of supervisory oversight is also being impacted because when vacancies
occur, supervisors are assisting with investigations which, in turn, limits their ability to
supervise the staff in their units. Similar issues were cited in a 1997 performance audit
of the Division’s investigative performance (Auditor General Report No. 97-18).
The Division indicates that it has already implemented or is in the process of
implementing additional steps to address unmanageable workloads and the limited
experience of some of its supervisors. Specifically:
􀁺􇩄 Division implementing strategies for recruiting and retaining staff—The Division
has initiated actions to improve staff recruitment and retention. For example, the
Division is participating in a multi-state, 5-year study to identify effective
strategies for recruiting and retaining quality and experienced case
management staff. As a part of this study, the Division has developed
recruitment and retention strategic plans for two pilot sites, one in Phoenix and
the other in Casa Grande. Some of the plans’ goals include developing local
recruiting plans, modifying the interview process, and providing prospective
candidates a better understanding of case management work using realistic job
videos. If these strategies prove successful, the Division plans to integrate the
project into its division-wide strategic plan.
The Division also continues to use stipends in an effort to recruit and retain case
management staff. For example, the Division has a $1,300-per-year "rural
recruitment and retention" stipend that is available to all CPS specialist IIs and
IIIs, supervisors, and program specialists in the four rural districts as these
individuals are responsible for ensuring the safety and welfare of children in their
communities 24 hours a day, 7 days a week. Similarly classified employees in
districts 1 and 2 do not receive the stipend because these districts have
permanent after-hour investigative teams available to provide 24-hour coverage.
In addition, in 2003 the Department received approval for an investigative
stipend. This stipend equals 10 percent of base pay and is available to
investigative workers with at least 36 months of CPS experience who take on 6
or more CPS reports during the month the reports are received. During fiscal
year 2005, the Division paid an average stipend of $2,306 to its case managers
State of Arizona
page 20
1 The additional positions are funded by General Fund and TANF appropriations and other nonappropriated federal
program monies.
2 Auditors noted some discrepancies in the Division’s reported filled positions, which the Division is working with auditors
to reconcile.
and supervisors, with the actual stipends ranging from $295 to $4,819. Finally,
according to division management, the Department has discussed with its
personnel office the possibility of offering a geographic stipend to attract and
retain staff in some of the “hard-to-staff” rural areas including Yuma, Bullhead
City, Kingman, Prescott Valley, Winslow, and Lake Havasu.
􀁺􇩄 Division implementing supports to help workers manage their workloads—The
Division has also taken action to help investigators manage their workloads. For
example, in April 2004, the Division began implementing a “support response
team” protocol that requires each district to make available one staff person to
assist with investigating CPS reports. If a district falls behind in responding to
investigations, the district e-mails the central office administrator, who will
approve the support team to assist the struggling district for up to 2 weeks.
According to division management, the team has been used three times.
Additionally, because of the vacancies in all the districts, the administrator has
been using central office staff with previous experience in CPS investigations,
supervision, and/or case management to provide assistance to the districts.
The Division is also establishing in-home service units, which it believes should
help reduce the workloads of some investigators. Typically, when an
investigative case is completed and findings have been recorded for all the
allegations, the case will be closed or transferred to an ongoing worker who will
arrange for and monitor the family’s participation in services.1 These ongoing
workers have traditionally managed both in-home and out-of-home cases. While
in-home services cases primarily involve monitoring a family’s voluntary
participation in services, out-of-home cases involve many additional actions
including filing a dependency petition, developing and monitoring a case plan,
and routinely meeting with the child and his or her family and foster caregiver.
According to division personnel, some investigators will retain an in-home
services case in their workload and monitor the family’s participation in services
rather than transfer it to an ongoing case manager they believe already has a
heavy workload. However, once the in-home services units are established, the
completed investigation cases requiring in-home services will be transferred to
these new units. The Division plans to staff the units with the 137 new case
management positions authorized in fiscal year 2006 and plans to have these
units in place in all districts by January 2006.
􀁺􇩄 Division implementing an online reporting tool to enhance reporting and
monitoring—According to the Division, it is implementing a new online
automated case management system reporting tool that will allow
management, supervisors, and CPS staff to view collected data, analyze trends,
and monitor performance. The Division plans to use the reporting tool initially to
report and monitor response times for CPS investigations, timeliness of CPS
investigations, and timeliness of case manager visitations with children and
Office of the Auditor General
page 21
1 The cases retained by investigators are those where the family is receiving services, but no children have been removed
from the home.
families. According to division management, the reporting tool will be
implemented in January 2006.
Although the Division plans to implement the tool to enhance its reporting of
automated case management data and monitoring of related CPS activities,
division management should not underestimate the impact that unreliable data
may have on the Division's ability to effectively implement the tool. In order for
the Division to fully utilize the tool and maximize its effectiveness, the data
maintained in the automated case management system must be timely,
complete, and accurate.
Additional steps needed to improve investigative performance—This
audit found that although the Division has policies and oversight processes that are
designed to help ensure that staff conduct timely and thorough investigations, these
mechanisms are not working as intended. Therefore, the Division needs to focus on
making meaningful changes to these mechanisms. Specifically:
􀁺􇩓 Streamline investigative tasks—The Division needs to significantly streamline the
investigative process. This recommendation is particularly important because it
is likely that the Division will always struggle with recruitment and retention
issues. This recommendation was most recently made in a May 2005
performance audit of CPS’ data integrity process (see Auditor General Report
No. CPS-0501). In that report, it was noted that the Division had established a
workgroup in 2002 to develop recommendations for reducing investigative tasks
while still ensuring children’s safety. However, this workgroup was only of limited
duration, and while it developed recommendations, they were not all
implemented. For example, the workgroup recommended that when law
enforcement involvement is necessary, the hotline worker rather then the CPS
unit should e-mail the police version of the CPS report directly to law
enforcement after sending the report to the responsible CPS investigative unit.
Further, the workgroup did not perform a comprehensive review of all the
processes impacting the investigations area and focused only on those
processes implemented state-wide, even though each district may develop
additional processes that take into account factors unique to them. Therefore,
the audit report recommended that the Division conduct a comprehensive and
systematic review of its processes to identify those that can be streamlined or
eliminated.
􀁺􇩉 Increase accountability—Division administration needs to determine its top
priorities for the investigative function and hold staff accountable for achieving
them. Specifically, the Division needs to identify the top three to five areas that
are most important to the investigative process and then focus on those areas.
Examples of potential priorities could include 1) investigating all CPS reports, 2)
conducting investigations according to statutory and policy requirements, 3)
documenting investigative activities completely and accurately, and 4) providing
required supervisory oversight.
State of Arizona
page 22
Division administration also needs to better use management reports to monitor
performance in these critical areas. While the Division has monthly exception
reports on issues such as reports missing allegation findings, as found in the
May 2005 CPS performance audit and this audit, the reports are not being
effectively used to resolve the exceptions. Also, although the six districts have
developed monitoring mechanisms, they are varied in terms of what and how
information is being tracked, and therefore, are of limited value to department
and division administration for tracking overall performance and targeting
problem areas. Therefore, the Division should revise or develop additional
management reports that will better allow administration to routinely assess
performance in critical areas, both overall and at targeted levels such as offices
or units. However, for these reports to be of value, the Division will need to
ensure the underlying data is accurate and complete.
Finally, division administration needs to establish accountability at all staff levels
for making sure the priorities are achieved. While the Division has a process for
evaluating staff performance against expected standards using annual written
evaluations, it appears that the evaluations are not always being conducted.
This may be partly because there is no central mechanism for tracking when
performance evaluations are due or performed. Department personnel
recognize the lack of a centralized mechanism as a barrier to ensuring that staff
evaluations are performed in a timely manner. However, it is left up to a worker’s
immediate supervisor to monitor this information. Auditors reviewed ten
personnel files and found that five were missing one or more required
evaluations. To ensure employees are held accountable for achieving the
Division’s priorities and expectations, the Division’s personnel unit should
implement a centralized tracking system to make certain staff receive their
required annual evaluation. Further, this tracking system should also record
each staff person’s overall performance rating for the year so that management
can readily identify those workers in need of corrective action.
􀁺􇩃 Communicate importance of documentation—Division management should
communicate to its employees the importance of recording timely, accurate,
and complete documentation in the automated case management system to
help ensure child safety and well-being. Management philosophy has a
significant influence on the Division’s operations and because of workload
concerns, management has notified case management staff that documenting
information is a secondary priority to ensuring child safety. However, the Division
should not overlook the negative impact that incomplete and untimely
documentation can have on a child’s continued safety and well-being, as well
as the investigator’s ability to investigate CPS reports and substantiate
allegations of abuse and neglect where appropriate.
Office of the Auditor General
page 23
Recommendations:
1. To ensure the Division‘s reported investigation rate accurately reflects
investigated reports, the Division should base the rate on the number of CPS
reports received that have findings for all allegations and for which the
supervisor has reviewed and approved the findings. This will require a
modification to the automated case management system to capture supervisor
approval of each of the allegation findings.
2. To ensure the Division can effectively monitor investigation timeliness, it needs
to take the following actions to better ensure accurate data on initial response
time:
a. Add edits to the automated case management system to prevent invalid
dates being input.
b. Clarify policy to clearly indicate that it is the CPS investigator’s response
time that must be recorded in the automated case management system,
even if emergency personnel are also involved.
c. Modify the automated case management system to allow the recording of
the assignment of a report with an unknown family surname and then later
merge it with any prior cases once the family surname becomes known.
3. To better ensure the safety and well-being of child victims of abuse and neglect,
the Division should investigate 100 percent of reports requiring CPS
investigation.
4. To improve the usefulness of the investigation closing summary documentation,
the Division should ensure that investigators document consistent and
comprehensive information.
5. To better ensure investigative performance is timely and thorough, the Division
should:
a. Establish three to five priorities that are most important to the investigative
function and would demonstrate that the Division is performing efficiently
and focus on these areas.
b. Develop and use additional management reports or other mechanisms to
keep division administration apprised of investigative performance in the
established priority areas so that timely corrective action can be taken if
needed.
State of Arizona
page 24
c. Hold staff accountable for achieving the Division’s priorities and
expectations by requiring the Division’s personnel unit to implement a
centralized tracking system to record when staff evaluations are due and
conducted and each person’s overall performance rating so that
management can readily identify those workers in need of corrective action.
6. Because of the negative impact that untimely, inaccurate, and incomplete
documentation can have on a child’s continued safety and well-being, as well
as an investigator’s ability to investigate CPS reports and substantiate
allegations of abuse and neglect where appropriate, division management
should communicate to staff the importance of recording timely, accurate, and
complete documentation in the automated case management system.
Office of the Auditor General
page 25
State of Arizona
page 26
Office of the Auditor General
page a-i
APPENDIX
State of Arizona
Office of the Auditor General
page a-iii
Appendix: Child Abuse Hotline Report Priority Classification System
Priority 1 High Risk
Response times:
• Standard within 2 hrs
• Mitigated within 24 hrs
Priority 2 Moderate Risk
Response times:
• Aggravated within 24 hrs
• Standard within 48 hrs
• Mitigated within 72 hrs
Priority 3 Low Risk
Response times:
• Aggravated within 48 hrs
• Standard within 72 hrs
• Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4 Potential Risk
Response times:
• Aggravated within 72 hrs
(excluding weekends and
holidays)
• Standard within 7 consecutive
days
Physical abuse:
Child death due to physical abuse
or neglect or suspicious death;
injuries requiring emergency
medical treatment; child under the
age of 6 observed or reported to be
struck in the head, face, neck,
genitals, or abdomen which could
likely cause injury; child under the
age of 24 months is shaken;
physical abuse by a parent,
guardian, or custodian who has a
previous substantiated priority 1
report or who threatens or presents
serious bodily harm to the child
now.
Physical abuse:
Injuries that may require medical
treatment; priority 3 injury to a child
under the age of 6; child 6 years of
age or older observed or reported
to be struck in the head, face,
neck, genitals, or abdomen which
could likely cause injury; parent,
guardian, or custodian presents
serious bodily harm to a child or
fears or threatens to harm child if
no intervention is received and he
or she has a previous
substantiated report of physical
abuse; child under 3 months of age
born to parents whose parental
rights have been previously
terminated.
Physical abuse:
Injuries not requiring medical
treatment such as cigarette burns,
single or small bruises, or injury to
buttocks or scalp; parent, guardian,
or custodian fears or threatens to
harm child if no intervention is
received.
Physical abuse:
Home environment stressors place
child at risk of physical abuse
which may include domestic
violence, mental illness, substance
abuse, history of physical abuse
with no current injuries, etc.
Sexual abuse:
Physical evidence of sexual abuse
reported by a medical doctor or
child reporting sexual abuse within
the past 7 days; child reporting
vaginal or anal penetration or oral
sexual contact within past 72 hours
and has not been examined by a
medical doctor.
Sexual abuse:
Sexual behavior within the past 8
to 14 days; attempted sexual
behavior or sexual behavior when
last occurrence is unknown or
when last occurred beyond 14
days and up to 1 year; parent,
guardian or custodian suggests or
entices a child to engage in sexual
behavior, but there is no actual
touching; child is exhibiting
physical or behavioral indicators
which are consistent with sexual
abuse and there are indicators the
behavior is caused by a parent,
guardian or caretaker; child is living
in the home with a person
convicted or a sexual offense
against a child.
Sexual abuse:
Parent guardian or custodian
sexually abused a child in the past
and is now living in a home with a
child; attempted sexual behavior or
sexual behavior when last
occurrence was beyond one year
and the perpetrator currently has
access to the child.
Sexual abuse:
NA
Emotional abuse:
NA
Emotional abuse:
Child diagnosed by a qualified
mental health professional as
exhibiting severe anxiety,
depression, withdrawal or
untoward aggressive behavior,
which could be due to serious
emotional damage by a parent,
guardian or custodian.
Emotional abuse:
Parent, guardian, or custodian
demonstrates behavior or child
reports parent, guardian or
custodian behavior which is likely
to have the effect of fear, rejection,
isolation, humiliation or
debasement of a child.
Emotional abuse:
NA
State of Arizona
page a-iv
Appendix: (Concluded)
Priority 1 High Risk
Response times:
• Standard within 2 hrs
• Mitigated within 24 hrs
Priority 2 Moderate Risk
Response times:
• Aggravated within 24 hrs
• Standard within 48 hrs
• Mitigated within 72 hrs
Priority 3 Low Risk
Response times:
• Aggravated within 48 hrs
• Standard within 72 hrs
• Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4 Potential Risk
Response times:
• Aggravated within 72 hrs
(including weekends and
holidays)
• Standard within 7 consecutive
days
Neglect:
Delayed or untreated medical
condition which is life-threatening
or permanently disabling; child of
any age who is left alone and
cannot care for self or for other
children due to physical, emotional,
or mental instability; child under the
age of 6 who is alone now; child 6
to 9 years of age is alone for 3
hours or longer or unknown when
parent, guardian or custodian will
return; imminent harm to child
under the age of 6 due to
inadequate supervision by parent,
guardian or custodian; neglect
results in serious physical injury or
illness requiring emergency
medical treatment; imminent harm
to child due to health or safety
hazards in living environment; child
assessed as suicidal by qualified
mental health professional and
parent, guardian or custodian is
unwilling to secure needed
emergency medical treatment; no
parent willing to provide immediate
care for a child and child is with
caregiver who is unable or
unwilling to care for the child now
or child is left to his or her own
resources; history of extensive
gestational substance abuse to
child under 3 months of age or
mother or child tests positive for
non-prescribed or illegal drug or
alcohol at time of birth; child under
2 months of age displays non-prescribed
or illegal drug or alcohol
withdrawal symptoms; mother is
using cocaine, heroin,
methamphetamines or PCP and is
breastfeeding a child.
Neglect:
Child age 11 to 13 years caring for
a child age 6 or younger for 12
hours or longer; living environment
presents health or safety hazards
to a child under the age of 6 which
may include human/animal feces,
undisposed garbage, exposed
wiring, access to dangerous
objects or harmful substances,
etc.; sexual conduct or physical
injury occurs between children due
to inadequate supervision or
encouragement by parent,
guardian or custodian; no parent
willing to care for a child and child
is with a caregiver who is unable or
unwilling to continue caring for the
child less than 1 week; child under
3 months of age born to parents
whose parental rights have been
previously terminated.
Neglect:
Delayed or untreated medical
problem caused child pain or
debilitation that is not life-threatening
and parent, guardian,
or custodian is unwilling to secure
medical treatment; child under the
age of 9 who is not alone at the
time of the report, but has been left
alone within the past 14 days;
parent, guardian or custodian
demonstrates an inability to care
for a child within the past 30 days
including leaving a child with
inappropriate or inadequate
caregivers; living environment
presents health or safety hazards
to a child 6 years of age or older
which may include human/animal
feces, undisposed garbage,
exposed wiring, access to
dangerous objects or harmful
substances, etc.; food not provided
and child is chronically hungry;
significant developmental delays
due to neglect; parent, guardian or
custodian is not protecting a child
from a person who does not live in
the home and who abused a child;
no parent willing to care for a child
and child is with a caregiver who is
unable or unwilling to continue
caring for the child beyond 1 week
up to 30 days; use of a child by a
parent, guardian or custodian for
material gain which may include
forcing the child to panhandle,
steal or perform other illegal
activities.
Neglect:
Parent, guardian, or custodian has
no resources to provide for child’s
needs including supervision, food,
clothing, shelter and medical care;
home environment stressors place
child at risk of neglect which may
include mental illness, substance
abuse, etc.; living environment is
likely to present a health or safety
hazard to a child; child adjudicated
dependent due to a finding of
incompetency or not restorable to
competency; sexual conduct or
physical injury between children
and unknown if parent, guardian or
custodian will protect; complaint by
law enforcement or officer of
juvenile court alleging dependency
due to a delinquent or incorrigible
act committed by a child under the
age of 8.
•
Office of the Auditor General
AGENCY RESPONSE
State of Arizona
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
1717 W. Jefferson • P.O. Box 6123 • Phoenix, AZ 85005
Janet Napolitano
Governor
David A. Berns
Director
December 14, 2005
Debbie Davenport
Auditor General
Office of the Auditor General
2910 North 44 Street, Suite 410
Phoenix, Arizona 85018
Dear Ms. Davenport:
The Department of Economic Security is pleased to provide the following comments to
supplement the CPS Investigations Performance Audit conducted by your office.
The rights of children to remain safe and in the care of their parents are among the
most fundamental. Child Protective Services protects children by investigating
allegations of abuse and neglect, promoting the well-being of children in permanent
homes, and coordinating services to strengthen families. The Department takes its
mission seriously and appreciates the work of your office in identifying areas of
practice requiring improvement, including investigation response time and timely date
entry into the case management information system.
The Audit conducted by your office covers a thirty-three month time period, specifically
from July 1, 2002 through March 31, 2005. During this almost three year period, our
Department’s Child Protective Services (CPS) received 91,267 CPS reports and
assigned one hundred percent (91,267) of these reports for investigation. As you have
acknowledged in your report, there has been a 27 percent increase in the number of
reports received and assigned for investigation by CPS (from 29,290 reports in 2003
to 37,170 reports in 2005).
Your office reviewed a computer report that identified cases in the database that were
missing two data elements: CPS response time and after investigation findings. Of
the 91,267 reports assigned during this period, you found 920 CPS reports, (1 percent
of the total number of CPS reports reviewed) that were missing these two data
elements. This missing information in the computer system raises questions as to
whether investigations had occurred for those reports. Your office selected 15 of
those reports, reviewed additional electronic and paper records, and found that 3 of
the 15 reports had not been investigated.
Debbie Davenport
Page 2
To ensure child safety, the Division reviewed the electronic and paper files of all 920
reports and determined that of the 920, an additional eight (8) reports had not been
investigated. Investigators were immediately instructed to locate the families involved
and complete safety and risk assessments of the children. In all but one case,
investigators were able to locate the families and take steps to ensure the children’s
safety. In the remaining case, the child had turned 18 since the report had been
received.
This Audit reinforced for the Department the findings of your office’s recent report
issued in May 2005, CHILDS Data Integrity Process, which identified the need for
more timely CPS data entry into the case management information system. The
Department is aggressively pursuing strategies to improve timely data entry, including
continual modification of the case management information system to make it more
efficient and easier to use and the implementation of a Business Intelligence
Dashboard which allows management, supervisors and CPS staff to view collected
data, analyze trends, and most importantly, monitor performance. CPS has prioritized
the following for the initial data display for this new automated tool: response time for
CPS investigations, timeliness of CPS investigations, and timeliness for case manager
visitation with children and families.
The Audit also found that many CPS reports were not responded to within the
timeframes established by our child welfare policy. Our policy was established to
assist CPS supervisors and workers in prioritizing their response to all the CPS
reports that have been assigned for investigation. Based upon additional information
obtained by CPS, such as from the reporting source, hospital personnel, or law
enforcement, CPS may determine that the child is safe and prioritize another CPS
report for response, when the safety of that alleged child victim is unknown. This may
result in an investigation being considered untimely according to our policy, but better
ensures that children are safe.
CPS workers are committed to providing timely and quality investigations. The
increased number of CPS reports that have been assigned for investigation over the
past several years have impacted investigation timeliness and data integrity. In
addition, staff turnover and vacancies have increased caseloads in some offices of the
state. The Department is working diligently to implement strategies to improve the
recruitment and retention of CPS staff, including participation in the Western Region
Recruitment and Retention project headed by the University of Denver.
Debbie Davenport
Page 3
I have also directed CPS to review our:
• Quality Assurance processes to ensure that the CPS investigation process,
including timeliness of initiating investigations, completion of after-investigation
findings, and thoroughness of investigation, are reviewed and
assessed on an ongoing basis.
• District tools used to monitor investigation status to ensure all areas of key
activity are being captured until all elements can be tracked automatically in
the Business Intelligence Dashboard.
We are committed to continued practice improvements, particularly as to data
integrity, retention of CPS staff and supervisors, and the quality and availability of CPS
training. All of these efforts will improve our investigation practice and documentation
of those investigations in the case management information system.
We are providing an attachment which addresses our plans for implementing the
recommendations suggested by your office. Please feel free to contact me at (602)
542-5678, or Tracy Wareing, Acting Deputy Director, Division of Children, Youth and
Families, at (602) 542-3598.
Sincerely,
David A. Berns
David A. Berns
Attachment
DES Response to Auditor General’s Report
CPS Investigations
1
DEPARTMENT OF ECONOMIC SECURITY
RESPONSE TO AUDITOR GENERAL’S REPORT
CHILD PROTECTIVE SERVICES PERFORMANCE AUDIT
DECEMBER 14, 2005
The Department of Economic Security (Department) is providing the following comments and responses
to the finding and recommendations of the Office of the Auditor General’s performance audit of
Division of Children, Youth and Families’ (Division) Child Protective Services (CPS) Investigations.
The rights of children to remain safe and in the care of their parents are among the most fundamental.
Child Protective Services protects children by investigating allegations of abuse and neglect, promoting
the well-being of children in permanent homes, and coordinating services to strengthen families. The
Department takes its mission seriously and appreciates the work of the Auditor General in identifying
areas of practice requiring improvement, including investigation response time and timely date entry
into the case management information system.
Because audits may guide public policy discussions and decisions, it is important to understand the full
context of the total number of CPS reports that were received and assigned for investigation during this
review period. The Auditor General conducted an audit that covers a thirty-three month time period,
specifically from July 1, 2002 through March 31, 2005. During this almost three year period, CPS
received 91,267 CPS reports and assigned one hundred percent (91,267) of these reports for
investigation. CPS was able to complete investigations on over 99.99 percent of these assigned 91,267
reports. As the Auditor General acknowledged, there has been a 27 percent increase in the number of
reports received and assigned for investigation by CPS (from 29,290 reports in 2003 to 37,170 reports in
2005).
The Auditor General reviewed a computer report that identified cases in the database that were missing
two data elements: CPS response time and after investigation findings. The Auditor General found 920
CPS reports, 1 percent of the total number of CPS reports reviewed, that were missing these two data
elements and questioned whether investigations had occurred for those reports. Based upon that finding,
the Auditor General selected 15 of those reports, reviewed additional electronic and paper records, and
found that 3 of the 15 reports had not been investigated.
To ensure child safety, the Division reviewed the electronic and paper files of all 920 reports and
determined that of the 920, an additional eight (8) reports had not been investigated. Investigators were
immediately instructed to locate the families involved and complete safety and risk assessments of the
children. In all but one case, investigators were able to locate the families and take steps to ensure the
children’s safety. In the remaining case, the child had turned 18 since the report had been received.
The Auditor General notes that the Division does not always initiate investigations within the required
timeframes. These timeframes were established to assist CPS supervisors and workers in prioritizing
CPS reports received and assigned for investigation. The Auditor General found that 54 percent of the
CPS investigations were responded to within the required timeframes and 12 percent were not responded
to within the required timeframes. The timeliness of the response in the remaining 34 percent of cases
could not be determined, although investigations were completed in all those cases. For the cases that
were not responded to within the required timeframes, 6,905 or 61 percent were identified as potential or
low risk reports; 3,185 or 28 percent missed the timeliness standard by one day or less and an additional
4,185 or 37 percent missed the timeliness standard by 2 to 5 days.
DES Response to Auditor General’s Report
CPS Investigations
2
The Division’s paramount concern is child safety. CPS supervisors and workers prioritize the order in
which CPS reports will be responded to from the information received from the statewide hotline and
information about the child’s immediate safety received from a variety of sources contacted after the
report is received. These include, but are not limited to; the reporting source, which may provide
additional information; the hospital, to determine a discharge date for a child that is hospitalized; and,
when law enforcement has made the initial response, the officers responding that have information about
the child’s safety. Although these steps help to ensure child safety, these contacts are not considered the
initial CPS response according to the Division’s child welfare policy and its database system. If the
child is determined safe, these initial actions allow CPS to prioritize other investigations that have been
assigned, ones in which child safety cannot be determined through additional contact with others.
Many of the findings in this most recent Auditor General’s report mirror findings in the Auditor’s May
2005 report on the CHILDS Data Integrity Process. CPS staff are committed to providing timely and
quality investigations. The increased number of CPS reports that are assigned for investigation impact
investigation timeliness and data integrity. To address the issues raised in the May 2005 audit, the
Department has committed to making practice improvements and increasing data integrity. In addition,
the Department is pursuing strategies to improve the recruitment and retention of CPS supervisors and
workers, and to increasing the quality and availability of CPS training. All of these efforts will improve
CPS investigation practice and documentation of those investigations in the case management
information system.
One example of these solutions, which will be implemented in January 2006, is the statewide use of a
user-friendly on-line reporting tool (Business Intelligence Dashboard) which allows management,
supervisors and CPS staff to view collected data, analyze trends, and most importantly, monitor
performance from the statewide level down to the worker level The Division has prioritized the
following for the initial data display for this new automated tool: response time for CPS investigations,
timeliness of CPS investigations, and timeliness for case manager visitation with children and families.
Additional data elements will be added after full implementation of this reporting tool.
The Department’s specific response to the Auditor General’s finding and recommendations follow in the
next section.
DES Response to Auditor General’s Report
CPS Investigations
3
RESPONSE TO REPORT FINDING
AND RECOMMENDATIONS
The Department’s response to the Auditor General finding and recommendations includes strategies that
the Division is currently implementing or will begin implementing. Many of these strategies include
modifications to the Division’s case management information system. The Division will begin
immediately to pursue the numerous steps necessary to modify an automated system. These
modifications will be made on an aggressive schedule in order to implement the agreed upon
recommendations of the Auditor General.
Recommendation 1:
To ensure the Division’s reported investigation rate accurately reflects investigated reports, the Division
should base the rate on the number of CPS reports received that have findings for all allegations and for
which the supervisor has reviewed and approved the findings. This will require a modification to the
automated case management system to capture supervisor approval of each of the allegation findings.
DES Response 1:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
The Division currently reports on the number of communications that meet the criteria of a report and
the number of those reports which have been dispositioned (assigned to a case worker) for investigation.
The Division will modify the report to include the number of investigations that have been closed. The
Division will modify the investigation closure process to require that all the findings of allegations of
abuse or neglect be entered into the automated system before the supervisor can approve the closure of
the investigation.
Target Completion Date: March 31, 2006
Recommendation 2a:
To ensure the Division can effectively monitor investigation timeliness, it needs to add edits to the case
management system to prevent invalid dates being input.
DES Response 2a:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will modify the automated system to ensure the following:
1) The response date cannot precede the communication received date.
2) The investigation cannot be closed unless a response date has been entered.
Target Completion Date: June 30, 2006
DES Response to Auditor General’s Report
CPS Investigations
4
In addition, the Division will research what potential modifications can be made to the automated case
management system to allow an “unknown” report to be assigned within the automated system and then
later merged with a prior case when the names of family members become known. Currently,
“unknown” CPS reports are assigned to the CPS worker who initiates the investigation but the CPS
report is not assigned in the case management information system until the surname of the family
becomes known. This prevents the creation of additional cases on the same family in the case
management information system that are not linked to one another. However, this results in invalid
dates in the case management information system.
Target Completion Date for Research: February 28, 2006
Recommendation 2b:
To ensure the Division can effectively monitor investigation timeliness, it needs to clarify policy to
clearly indicate that it is the CPS investigator’s response time that must be recorded in the automated
case management system, even if emergency personnel are also involved.
DES Response 2b:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
DES agrees that it is the CPS investigator’s response time that must be recorded in the automated case
management system. In addition, DES believes that it is also important to document when emergency
personnel have provided first response and have ensured child safety.
The Division will clarify with CPS staff the policy when they can indicate someone other than CPS
conducted the initial response and the subsequent time frame for CPS to initiate their investigation
Target Completion Date: December 31, 2005
In addition, the Division will modify the automated case management information system to allow entry
of both the initial CPS response time and the initial response time of emergency personnel, when
emergency personnel response has ensured child safety.
Target Completion Date: June 30, 2006
Recommendation 2c:
To ensure the Division can effectively monitor investigation timeliness, it needs to modify the
automated case management system to allow the recording of the assignment of a report with an
unknown family surname and then later merge it with any prior cases once the family surname becomes
known.
DES Response to Auditor General’s Report
CPS Investigations
5
DES Response 2c:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will research what potential modifications can be made to the automated case management
system to allow an “unknown” report to be assigned within the automated system and then later merged
with a prior case when the names of family members become known. Currently, “unknown” CPS
reports are assigned to the CPS worker who initiates the investigation but the CPS report is not assigned
in the case management information system until the surname of the family becomes known. This
prevents the creation of additional cases on the same family in the case management information system
that are not linked to one another. However, this results in invalid dates in the case management
information system.
Target Completion Date for Research: February 28, 2006
Recommendation 3:
To better ensure the safety and well being of child victims of abuse and neglect, the Division should
investigate 100 percent of reports requiring investigation.
DES Response 3:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Recommendation 4:
To improve the usefulness of the investigation closing summary documentation, the Division should
ensure investigators document consistent and comprehensive information.
DES Response 4:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will incorporate the CPS supervisor’s review of this requirement through the development
and implementation of an “investigation case closure” template. This template will contain all the
necessary elements the CPS supervisor needs to review prior to investigation case closure, including
documentation of consistent and comprehensive information.
Target Completion Date for Template Implementation: January 31, 2006
Recommendation 5a:
To better ensure investigative performance is timely and thorough, the Division should establish three to
five priorities that are most important to the investigative function and would demonstrate that the
Division is performing efficiently and focus on these areas.
DES Response to Auditor General’s Report
CPS Investigations
6
DES Response 5a:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Based up the Auditor General’s recommendation, the Division established and set the following
priorities: Response Timeliness, Investigation Completion, and Documentation.
The first two priorities are key performance indicators that are in the Business Intelligence Dashboard.
The Business Intelligence Dashboard will record an investigation as completed when all the allegation
findings are entered. The third priority, documentation, is addressed within the Division’s response to
the Auditor General’s number 4 recommendation.
Target Completion Date: January 31, 2006
The Division will continue to look for opportunities to better ensure timely and thorough investigations.
Recommendation 5b:
To better ensure investigative performance is timely and thorough, the Division should develop and use
additional management reports or other mechanisms to keep Division administration apprised of
investigative performance in the established priority areas so that timely corrective action can be taken if
needed.
DES Response 5b:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division has taken the following steps to improve the development and use of management tools to
monitor performance:
• The Division is implementing a user-friendly on-line reporting tool (Business Intelligence
Dashboard) which will allow management, supervisors and CPS staff to view collected data, analyze
trends, and most importantly, monitor performance. The Division has prioritized the following for
the initial data components for this new automated tool: response time for CPS investigations,
timeliness of CPS investigations, and timeliness for case manager visitation with children and
families. This new tool will be available in January 2006, and will portray data on a statewide,
district, unit, and individual worker basis.
• In October 2005, the Division initiated monthly learning sessions with the Practice Improvement
Specialists (including Central Office and District staff), District Automation Liaisons (DALs),
Division Reports & Statistics staff, the Program Administrator for Finance and Business Operations,
and the District Program Managers to train staff on the use of data. The initial training was provided
by the National Resource Center for Child Welfare Data and Technology and the National Resource
Center for Organization Improvement on October 6th & 7th. The focus of the first learning session
was to develop a baseline of knowledge and understanding around child welfare data. The second
session occurred on November 16, 2005 and focused on some of the current reports which are
DES Response to Auditor General’s Report
CPS Investigations
7
distributed to the Districts, including exception reports. One of the goals of these sessions is to
develop the knowledge and expertise of the staff whose responsibility it is to use data and
management reports to inform and monitor practice.
• Case Reviews are completed on a random sample of cases in each district to monitor performance
based upon the federal Child and Family Service Review. This review includes timeliness of
investigations and other critical functions. After each district review, the findings are reviewed with
Division and District staff. The Case Review mirrors the federal Child and Family Service
Performance measures and identifies the percentage of investigations initiated within state policy
timeframes. These reviews have not identified any uninvestigated reports.
The Division will continue to implement the above strategies and look for other opportunities to monitor
CPS performance.
Recommendation 5c:
To better ensure investigative performance is timely and thorough, the Division should hold staff
accountable for achieving the Division’s priorities and expectation by requiring the Division’s personnel
unit to implement a centralized tracking system to record when staff evaluations are due and conducted
and each person’s overall performance rating so that management can readily identify those workers in
need of corrective action.
DES Response 5c:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
DES concurs that the timely completion of performance evaluations (ESTEEM) for staff is a critical
component of management. Unfortunately, there is no automated system that can generate reports to
identify which staff have past due ESTEEMs or which staff have upcoming ESTEEMs. DES is working
with the Department of Administration (ADOA) to determine if it is possible to establish an interface
between the ADOA Human Resource Information System (HRIS) and the DES Financial Management
Control System (FMCS) Data Warehouse to generate these reports. DES understands that ADOA is
also exploring an automated tracking system for PASE which is the staff evaluation format being used
by ADOA and most other state agencies. If that evaluation process can be automated more easily and
quickly than developing an interface for HRIS and FMCS, DES would prefer to change to the PASE
evaluation process, rather than developing a duplicate staff evaluation tracking system.
Recommendation 6:
Because of the negative impact that untimely, inaccurate, and incomplete documentation can have on a
child’s continued safety and well-being, as well as an investigator’s ability to investigate CPS reports
and substantiate allegations of abuse and neglect where appropriate, Division management should
communicate the importance of recording timely, accurate, and complete documentation in the
automated case management system.
DES Response to Auditor General’s Report
CPS Investigations
8
DES Response 6:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will continue to communicate the importance of accurate and timely case documentation.
During initial case manager core training, accurate and timely case documentation is trained and the
importance emphasized.
The Division will send a reminder to CPS staff regarding the importance of recording timely, accurate,
and complete documentation in the automated case management system.
Target Completion Date: December 16, 2005
The Division will develop and distribute documentation guides for CPS supervisors and workers.
Target Completion Date: February 15, 2006
The Division will develop and implement an advanced training class on documentation. All CPS
supervisors and workers will be required to attend this training.
Target Completion Date Curriculum Development: February 28, 2006
_______________________________________________
CPS Performance Audits and Information Briefs Issued
Future CPS Performance Audits
Training
Future CPS Information Briefs
Types of Federal Monies Available
CPS Performance Audits
CPS-0501 CHILDS Data
Integrity Process
Information Briefs
IB-0401 Federal IV-E Waiver Demonstration
Project Proposal
IB-0501 Family Foster
Homes and Placements
IB-0502 Revenue Maximization

Copyright to this resource is held by the creating agency and is provided here for educational purposes only. It may not be downloaded, reproduced or distributed in any format without written permission of the creating agency. Any attempt to circumvent the access controls placed on this file is a violation of United States and international copyright laws, and is subject to criminal prosecution.

Debra K. Davenport
Auditor General
Performance Audit
Department of Economic
Security–Division of Children, Youth
and Families—Child Protective Services—
Timeliness and Thoroughness of Investigations
Performance Audit Division
DECEMBER • 2005
REPORT NO. CPS-0502
A REPORT
TO THE
ARIZONA LEGISLATURE
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five senators
and five representatives. Her mission is to provide independent and impartial information and specific recommendations to
improve the operations of state and local government entities. To this end, she provides financial audits and accounting services
to the State and political subdivisions, investigates possible misuse of public monies, and conducts performance audits of
school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Senator Robert Blendu, Chair Representative Laura Knaperek, Vice Chair
Senator Carolyn Allen Representative Tom Boone
Senator Gabrielle Giffords Representative Ted Downing
Senator John Huppenthal Representative Pete Rios
Senator Harry Mitchell Representative Steve Yarbrough
Senator Ken Bennett (ex-officio) Representative Jim Weiers (ex-officio)
Audit Staff
Melanie Chesney, Director and Contact person
Dot Reinhard, Manager
Catherine Dahlquist, Team Leader
Steven Montague
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.azauditor.gov
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 19, 2005
Members of the Arizona Legislature
The Honorable Janet Napolitano, Governor
Mr. David A. Berns, Director
Department of Economic Security
Transmitted herewith is a report of the Auditor General, A Performance Audit of the Department of
Economic Security, Division of Children, Youth and Families—Child Protective Services—Timeliness and
Thoroughness of Investigations. This audit was conducted under the authority vested in the Auditor
General by Arizona Revised Statutes §41-1966.
The report addresses the need for the Division to improve its investigations of child abuse and neglect
reports. Investigations are a critical first step to ensuring children’s safety and well-being. As such, it is
important that investigations be timely as any delay may further jeopardize the safety of the child.
Likewise, it is important that the investigation of the circumstances leading to the CPS report be thorough
so that the services and supports needed to ensure safety and well-being can be provided.
The report found that even though the Division is statutorily required to investigate all reports in a prompt
and thorough manner, some reports were not investigated, and many reports that were investigated did
not meet statutory or division requirements for timeliness and thoroughness. The Division believes that
unmanageable workloads, staff turnover, and the limited experience of some CPS supervisors and newly
hired investigators are the primary contributing factors to its investigation problems and continues to take
steps to address these issues. However, since these factors are likely to continue, additional meaningful
changes are needed, including streamlining the investigation process and establishing effective oversight
and accountability mechanisms.
As outlined in its response, the Department of Economic Security agrees with the finding and plans to
implement or implement in a different manner all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 20, 2005.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
Office of the Auditor General
TABLE OF CONTENTS
continued
1
9
9
10
12
16
18
19
24
a-i
a-iii
1
7
15
15
Introduction & Background
Finding 1: Investigations need to be improved
to better ensure children’s safety
Investigations help ensure children are safe
Division failed to investigate some CPS reports
Division has not conducted some investigations and other actions
in a timely manner
Some investigations not thorough
Investigation documentation not always current, accurate, or
complete
Additional actions needed to improve investigative performance
Recommendations
Appendix
Child Abuse Hotline Report Priority Classification System
Agency Response
Figures:
1 Child Abuse and Neglect Reports
Fiscal Years 2003 Through 2005
2 Number of Offices by District
Fiscal Year 2005
3 Compliance with Entering Allegation Findings
Within 21 Days of Report Receipt
Reports Received from July 1, 2002 Through March 31, 2005
4 Compliance with Closing or Transferring Investigations
Within 45 Days of Report Receipt
Reports Received from July 1, 2002 Through March 31, 2005
page i
State of Arizona
TABLE OF CONTENTS
Tables:
1 Summary of Child Abuse Report Priority Classification System
2 Child Abuse and Neglect Allegations
by Type and Priority
Fiscal Years 2003 Through 2005
3 Number of Children Removed
from Their Homes by the Department
April 1, 2001 Through March 31, 2005
4 Compliance with Initiating Investigations
Within Policy Time Frames
Reports Received from
July 1, 2002 Through March 31, 2005
3
4
6
13
concluded
page ii
The Office of the Auditor General has conducted a performance audit of Child
Protective Services’ (CPS) ability to respond to and investigate allegations of child
abuse and neglect in a timely and thorough manner. CPS is a program within the
Department of Economic Security’s (Department) Division of Children, Youth and
Families (Division). This audit was conducted under the authority vested in the
Auditor General by Arizona Revised Statutes §41-1966.
The Division’s CPS program is intended to
protect children by investigating allegations
of abuse and neglect while promoting the
well-being of children in permanent homes
and coordinating services to strengthen
families. In fiscal year 2005, the Division
received 37,545 reports alleging abuse or
neglect involving 47,638 children.1, 2 As
shown in Figure 1, the number of reports
received has increased by about 2,500
reports, or 7 percent, between fiscal years
2003 and 2005. During the same time
period, the number of reports requiring
investigation by CPS has increased by 27
percent, from 29,290 in fiscal year 2003 to
37,170 in fiscal year 2005.3 Some of this
increase is due to a legislative change that
requires all reports previously referred to the
Family Builders program to now be
investigated by CPS.4 The number of children
Office of the Auditor General
INTRODUCTION
& BACKGROUND
page 1
Reports Received
Figure 1: Child Abuse and Neglect Reports
Fiscal Years 2003 Through 2005
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and June 30, 2005, maintained in the
Department's Children's Information Library and Data Source system.
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
FY2003 FY2004 FY2005
Reports requiring CPS investigation Family Builders and other (tribal/military)
N=35,032
N=39,549 N=37,545
1 Auditor General staff calculation based on automated CPS case data for fiscal year 2005 provided by the Arizona
Department of Economic Security.
2 Children involved in one or more reports of abuse or neglect are counted only once.
3 The number of reports may vary slightly from those cited in division-prepared documents because of differences in the
dates the information is extracted from the automated case management system. Because the system is real-time
based, information is constantly being updated. The data auditors reported was extracted in July and August of 2005.
4 Prior to fiscal year 2005, CPS could refer certain low-risk and potential-risk child abuse reports to the Family Builders
program. At that time, the program was an alternative response system comprising a network of community-based
providers offering family-centered assessment, case management, and services. The reports referred to Family Builders,
which totaled 5,464 in fiscal year 2003 and 5,128 in fiscal year 2004, were not investigated by CPS. However, as of July
2004, all reports, unless falling outside the agency’s jurisdiction, must be investigated by CPS.
involved in CPS reports has grown 5.6 percent during the same time, which is in-line
with Arizona’s population growth of 5.2 percent.1
Investigations initiated by CPS reports
Reports of suspected child abuse are referred to CPS
through a state-wide, toll-free, 24-hour child abuse
hotline. Although anyone can report suspected abuse,
more than half the communications are made by people
who are mandated by law to report such instances, such
as law enforcement personnel, school personnel,
doctors, and other healthcare professionals. Centralized
hotline workers respond to all telephone and written
communications using a screening process to determine
whether the situation warrants an investigation. During
fiscal year 2005, the hotline received 111,539
communications, with 37,170 (33 percent) meeting the
criteria for a CPS investigation.2 In addition to
determining which communications require a CPS
investigation, hotline workers prioritize the reports, which
determines how quickly an investigation must be started.
As summarized in Table 1 (see page 3), the Division uses
four categories to prioritize investigations, with the
standard response time ranging from 2 hours for priority
1 reports, which are the most serious, to 7 days for
priority 4 reports, which are considered potential abuse
or neglect situations.3 (See Appendix, pages a-iii to a-iv,
for detailed information about the priority classification
system).
A CPS report may include more than one allegation.
Allegations are based on type of abuse and neglect, its severity, and the reported
victim. For example, the report may include an allegation of priority 1 physical abuse
for one child and priority 2 neglect for the same child and a sibling for a total of three
allegations. As noted in Table 2 (see page 4), the percentage of allegations by type
of abuse and neglect has remained stable across the past 3 years with neglect
State of Arizona
page 2
CPS Report Criteria
A communication meeting the criteria for investigation must
include:
􀁺􇩁 An allegation that a person under the age of 18 is the
subject of physical, sexual, or emotional abuse, neglect,
abandonment, or exploitation;
􀁺􇩁 A parent, guardian, or custodian has:
􀂍􈵩 inflicted,
􀂍􈵭 may inflict,
􀂍􈵰 permitted another person to inflict, or had reason to
know another person may inflict,
􀂍􈵯 or the alleged abusive person has not been identified
and the parent, guardian, or custodian has not been
ruled out as the person who inflicted, permitted
another person to inflict or had reason to know
another person would inflict abuse or neglect; and
􀁺􇩃 Contains sufficient information to locate the child.
Source: Department’s Child Abuse Hotline Procedures Manual.
1 Auditor General staff calculation of Arizona’s population and CPS report growth rates was based on U.S. Census Bureau
estimates for July 1, 2003, projections for July 1, 2005, and automated CPS case data for fiscal years 2003 through 2005
provided by the Arizona Department of Economic Security.
2 In addition to the communications requiring CPS investigation, the hotline received 357 communications requiring
investigation that fell within the jurisdiction of military and tribal governments and were referred to those jurisdictions.
3 The standard priority timeline for starting an investigation can be aggravated or mitigated by a hotline worker or CPS
supervisor based upon extenuating circumstances. For example, when a hospital worker makes a report to the hotline on
a newborn testing positive for exposure to an illegal substance, the report will be assigned a priority 1. However, the
response time of 2 hours may be mitigated by the hotline worker to 24 hours if the child is safe in the hospital and will not
be released for at least another day.
Office of the Auditor General
page 3
Table 1: Summary of Child Abuse Report Priority Classification System
Priority 1
High Risk
Response times:
Standard within 2 hrs
Mitigated within 24 hrs
Priority 2
Moderate Risk
Response times:
Aggravated within 24 hrs
Standard within 48 hrs
Mitigated within 72 hrs
Priority 3
Low Risk
Response times:
Aggravated within 48 hrs
Standard within 72 hrs
Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4
Potential Risk
Response times:
Aggravated within 72 hrs
(excluding weekends and
holidays)
Standard within 7 consecutive
days
Physical abuse:
Child death due to abuse,
neglect, or suspicious death;
severe or life threatening
injuries requiring emergency
medical treatment; and/or
parent presents severe
physical harm to the child
now.
Physical abuse:
Serious or multiple injuries
which may require medical
treatment, and/or a child is at
risk for serious physical abuse
if no intervention is received.
Physical abuse:
Injuries not requiring medical
treatment, and/or parent
threatens physical harm to
child if no intervention is
received.
Physical abuse:
Child at risk of physical injury
due to stressors in the home.
Neglect:
Severe or life-threatening
situations requiring
emergency intervention due
to the absence of a parent, or
a parent who is either unable
due to physical or mental
limitations or is unwilling to
provide minimally adequate
care.
Neglect:
Serious or non-life-threatening
situations requiring intervention
due to the absence of a parent,
or a parent who is either
unable due to physical or
mental limitations or is
unwilling to provide minimally
adequate care.
Neglect:
Situations which may require
intervention due to the
absence of a parent, or a
parent who is either unable
due to physical or mental
limitations or is unwilling to
provide minimally adequate
care, which includes
exploitation of a child.
Neglect:
Child at risk of neglect due to
stressors in the home.
Sexual abuse:
Physical evidence of sexual
abuse reported by a medical
doctor or child reporting
sexual abuse within the past 7
days.
Sexual abuse:
Sexual behavior or attempted
sexual behavior occurring 8
days or up to one year ago,
and/or child is exhibiting
indicators consistent with
sexual abuse.
Sexual abuse:
Sexual behavior or attempted
sexual behavior occurring
beyond one year and
perpetrator currently has
access to a child.
Sexual abuse:
NA
Emotional abuse:
NA
Emotional abuse:
Child diagnosed by a mental
health professional as
exhibiting symptoms of
emotional abuse caused by a
parent.
Emotional abuse:
Parent demonstrates
behavior which may result in
emotional trauma to a child.
Emotional abuse:
NA
Source: Department’s Child Abuse Hotline Procedures Manual.
State of Arizona
page 4
Table 2: Child Abuse and Neglect Allegations
by Type and Priority
Fiscal Years 2003 Through 2005
Fiscal Years
2003 2004 2005
Number
of
Allegations
Percentage
of
Total Allegations
Number
of
Allegations
Percentage
of
Total Allegations
Number
of
Allegations
Percentage
of
Total Allegations
Physical Abuse
Priority 1 641 1% 786 1% 689 1%
Priority 2 3,496 5 3,999 5 3,811 5
Priority 3 7,119 11 8,139 11 8,736 11
Priority 4 4,862 8 5,425 7 6,228 8
Subtotal 16,118 25 18,349 24 19,464 25
Sexual Abuse
Priority 1 292 <1 355 <1 383 <1
Priority 2 2,036 3 2,377 3 2,224 3
Priority 3 1,323 2 1,409 2 1,340 2
Priority 4 NA 1 NA NA
Subtotal 3,651 5 4,141 5 3,947 5
Emotional Abuse
Priority 1 NA NA NA
Priority 2 129 <1 182 <1 142 <1
Priority 3 1,253 2 1,601 2 1,422 2
Priority 4 NA NA NA
Subtotal 1,382 2 1,783 2 1,564 2
Neglect
Priority 1 7,193 11 9,288 12 9,101 11
Priority 2 10,647 17 13,510 18 12,633 16
Priority 3 17,365 27 20,191 27 22,826 28
Priority 4 8,164 13 8,950 12 10,699 13
Subtotal 43,369 68 51,939 69 55,259 68
Death by Abuse
Priority 1 22 <1 53 <1 42 <1
Death by Neglect
Priority 1 22 <1 24 <1 35 <1
Total allegations in CPS
reports requiring
investigations
64,564
100%
76,289
100%
80,311
100%
1 NA indicates the category has no priority classification.
Source: Auditor General staff analysis of CPS data maintained in the Department’s Children’s Information Library and Data Source system.
Office of the Auditor General
page 5
allegations comprising approximately two-thirds of total annual allegations. Similarly,
the distribution of allegations by priority has also remained relatively stable over the
years, with priority 1 allegations typically comprising the smallest percentage and
priority 3 allegations typically comprising the largest percentage.
When it is determined that a CPS investigation is
necessary, an investigative case manager will
complete activities such as interviewing the alleged
victim(s), perpetrator(s), and other knowledgeable
sources to help assess the risk of harm to the child or
children involved and evaluate the conditions that
support or refute the alleged abuse or neglect. Statute
requires that a finding be documented on each
allegation within 21 days of the CPS report being
made. Potential findings include “proposed
substantiated,” “unsubstantiated,” or “unable to
locate.”
Based on the investigation, the Division may take one
or more of the following actions:1
􀁺􇨠 Close the case—When the Division determines
there are no risk factors severe enough to warrant
ongoing involvement to ensure the children’s
safety, the Division may close the case after
investigation without providing further services. Alternately, a case may be
closed if the family refuses offered services and the risks to the child’s safety
are not severe enough to warrant legal action. The Department’s automated
CPS data indicates that 18,615, or 50 percent, of CPS reports received in fiscal
year 2005 were closed after investigation without the family receiving services.2
􀁺􇩐 Provide short-term services—When the Division determines that a child is at risk
for maltreatment, it may offer the family services such as counseling and parent
skills training that could allow the child to live safely at home. These services,
referred to as in-home services, may be provided directly by department staff,
by contract, or through referral to community agencies. The services are
typically provided for several weeks to several months, and the families
participate in them voluntarily. The Department’s automated CPS data indicates
that the families who were associated with 14,416, or 39 percent of CPS reports
received in fiscal year 2005, were provided with in-home services.
Criteria for Allegation Findings
􀁺􇩐 Proposed substantiated is used when there is
probable cause, i.e., facts that provide reasonable
grounds to believe the alleged abuse or neglect
occurred.
􀁺􇩕 Unsubstantiated is used when there is not probable
cause to believe the alleged abuse or neglect
occurred.
􀁺􇩕 Unable to locate is used when the child victim cannot
be located and there is insufficient evident to
conclude that the child was abused or neglected
without interviewing or observing the child.
Source: Department’s Children’s Services Manual.
1 The number of actions cited in the following bullets is based on the information recorded in the Division’s automated
case management system as of August 9 and 10, 2005.
2 Although families may not have received services paid for through the Department, they still may have been referred to
community services. However, the Division does not currently have a mechanism for tracking this information.
􀁺􇩆 File an in-home dependency or in-home intervention dependency—When the
Division determines that a child is currently safe but is at high risk of harm, and
safeguards can be established to maintain the child’s continued safety and well-being
in his or her home, CPS may file an in-home dependency or an in-home
intervention dependency with the local juvenile court. An in-home dependency
petition, if approved by the court, makes the child a ward of the court and places
the child in the physical custody of his/her parent(s). Under an in-home
intervention dependency, the child is allowed to stay in his or her home when
short-term intervention—up to 1 year—appears likely to resolve risk issues and
the parent, guardian, or custodian agrees to a case plan and participation in
services. The child does not become a ward of the court. However, if the parent,
guardian, or custodian fails to comply with the case plan, the court may take
whatever steps it deems necessary to obtain compliance or may award custody
of the child to the State, at which time the child may be placed in out-of-home
care. According to the Attorney General’s Office, between January 1, 2004 and
November 15, 2005, there were 360 in-home dependency petitions filed. In
addition, there were 39 in-home intervention dependency petitions
filed between January 1, 2004 and November 10, 2005.
􀁺􇩆 File an out-of-home dependency—When the Division
determines that a child is in imminent danger of abuse or
neglect, he or she may be removed from the home and
temporarily placed in an approved foster care setting, such
as with a relative or in a licensed foster or group home.1
When this happens, the Division must either file a
dependency petition with the local juvenile court within 72
hours or return the child to his or her family. If the court
determines the child to be dependent, it will award custody to
the State, and the child will remain in an out-of-home
placement until the parent(s) address(es) the risk factors that
prevent him and/or her from caring for the child safely at
home. According to a department report, the number of
children removed from their homes semiannually has
increased by more than 50 percent between April 2001 and
March 2005, with the greatest increases occurring between
October 2002 and September 2003, as illustrated in Table 3.
State of Arizona
page 6
Table 3: Number of Children Removed
from Their Homes by the Department
April 1, 2001 Through March 31, 2005
Reporting period
Number
of children
removed
Semiannual
percent change
Apr 2001 – Sept 2001 2,387 NA
Oct 2001 – Mar 2002 2,501 5%
Apr 2002 – Sept 2002 2,655 6%
Oct 2002 – Mar 2003 2,961 12%
Apr 2003 – Sept 2003 3,349 13%
Oct 2003 – Mar 2004 3,504 5%
Apr 2004 – Sept 2004 3,630 4%
Oct 2004 – Mar 2005 3,617 0%
Source: Child Welfare Reporting Requirements Semi-annual
Report prepared by the Arizona Department of Economic
Security, Division of Children, Youth and Families,
Administration for Children, Youth and Families.
1 When CPS removes a child from his or her home, the Department is required to conduct a Removal Review Team
conference within 72 hours of the child’s removal. The purpose of this conference is to determine whether the removal
was necessary, if there are alternatives to continued out-of-home placement, or if continued out-of-home placement is
necessary and, therefore, an out-of-home dependency petition must be filed. Per A.R.S. §8-822, the Removal Review
Team consists, at a minimum, of a CPS case manager and his or her supervisor, two members of the Foster Care Review
Board, and the child’s physician if the child has a medical need or chronic illness. If all reasonable efforts to reach the
child’s physician have been made and the physician is not available, the team shall include a licensed physician who is
familiar with children’s healthcare. Other qualified individuals such as a counselor or therapist may also be included in the
review.
Organization, staffing, and budget
The CPS program provides child welfare services
throughout the State. In order to accomplish this, CPS
is organized into 68 offices within 6 regional districts
(see Figure 2).1 These offices are composed of one or
more units typically consisting of a supervisor, 5 to 7
case managers, a case aide, and a secretary. In
Districts I and II, the two urban districts, unit function is
generally specialized. For example, case managers in
one unit may handle only CPS investigations, while
another unit may handle only ongoing services cases.
In the 4 rural districts, the case managers in a single
unit may be required to perform both investigations
and ongoing case management. However, according
to division management, each unit has at least one
case manager dedicated to conducting CPS
investigations.
The majority of the Division’s employees work within
the CPS program. The remaining employees provide
administrative and support services to the Division.
According to the Department, in fiscal year 2005, the
Division had 1,793 full-time equivalent (FTE) positions,
of which 871 were CPS specialists (i.e., case
managers) and 152 were CPS supervisors.2 In addition, there were another 4 FTEs
classified as human service specialists who also manage CPS cases.
To provide CPS services, the Division receives both state and federal funding.
Although the Division does not track expenditures by functional area, the Division
estimates that it expended approximately $23 million on salaries and benefits for
investigative and hotline staff in fiscal year 2005.3 Part of the expenditure was for a
stipend intended to help in the recruitment and retention of investigators that was
Office of the Auditor General
page 7
District IV
8 Offices
District I
19 Offices
District II
10 Offices
District III
12 Offices
District V
9 Offices
District VI
10 Offices
Figure 2: Number of Offices by District
Fiscal Year 2005
Source: Auditor General staff analysis of the Division of Children, Youth and Families’
Directory of Child Protective Services Offices.
1 In addition to the 68 CPS offices, the Division has case management staff assigned to 7 non-DES locations, such as the
Mesa Center Against Family Violence.
2 The numbers of CPS specialist and supervisor FTEs include 42 CPS specialists and 7 supervisors who work at the
hotline, and exclude 47 CPS specialist FTE positions assigned for trainees. The Division’s positions are funded by
General Fund and Temporary Assistance for Needy Families (TANF) program appropriations and other nonappropriated
federal program monies.
3 The Division estimated its investigative staff salary and benefit expenditures using the federally approved Arizona
Random Moment Sample (RMS) time study methodology. This methodology measures the work effort of the entire group
of eligible staff involved in the CPS program by sampling and analyzing the work efforts of a cross-section of the group.
RMS methods employ a technique of polling employees at random moments over a given time period to determine the
nature of the employee’s work activities and tallying the results of the polling. The method provides a statistically valid
means of determining what portion of the selected group of staff’s workload is spent performing activities that are
reimbursable by the federal government to allocate the labor costs of direct service staff to appropriate federal and state
funding sources.
authorized during the 2003 Second Special Session.1 The stipend equals 10 percent
of a worker’s base salary and is paid on a monthly basis to those investigators with
at least 36 months of CPS experience who are assigned 6 or more CPS reports to
investigate in the same month the reports are received. These reports are in addition
to any existing cases already being worked by the investigator. The Division reports
that it expended $538,000 on the investigative stipend in fiscal year 2005.
1 Legislation passed during the 2003 Second Special Session did not authorize any additional monies to the Department
for the stipend.
State of Arizona
page 8
Investigations need to be improved to better
ensure children’s safety
To better ensure children’s safety, the Division needs to improve its investigations of
child abuse and neglect reports. Investigations are a critical first step to ensuring
children’s safety and well-being. However, even though the Division is statutorily
required to investigate all reports, some reports were not investigated, and many
reports that were investigated did not meet statutory or division requirements for
timeliness and thoroughness. The Division believes that unmanageable workloads,
staff turnover, and the limited experience of some CPS supervisors and newly hired
investigators are the primary contributing factors to its investigation problems and
continues to take steps to address these issues. However, since these factors are
likely to continue, additional meaningful changes are needed, including streamlining
the investigation process and establishing effective oversight and accountability
mechanisms.
Investigations help ensure children are safe
Investigating child abuse and neglect reports is a critical first step for ensuring
children’s immediate safety and long-term well-being. As such, it is important that
investigations be timely as any delay may further jeopardize the child’s safety.
Likewise, it is important that the investigation of the circumstances leading to the CPS
report be thorough so that the services and supports needed to ensure safety and
well-being can be provided. In addition to the immediate safety issue, there may be
potential long-term consequences for children left in situations where they may be
abused or neglected. According to a report from the National Clearinghouse on Child
Abuse and Neglect Information, studies have found that abuse and neglect can have
long-term physical, emotional, and behavioral consequences.1 For example, shaking
a baby (a form of physical abuse) may result in blindness, learning disabilities, mental
retardation, or paralysis. Further, it is important that the information obtained during
an investigation is documented in a timely manner in the automated case
Office of the Auditor General
FINDING 1
page 9
1 National Clearinghouse on Child Abuse and Neglect Information. Long-term Consequences of Child Abuse and Neglect.
Washington, D.C. (July 2005).
management system so that it is readily available to other CPS staff and
management who may need it, such as after-hours staff responding to a subsequent
report or supervisors monitoring workload and productivity.
Division failed to investigate some CPS reports
The Division has not investigated some of the CPS reports it has received. Further,
auditors identified some additional reports for which it is unclear whether
investigations were conducted or thoroughly completed. Despite this, the Division
has been reporting to the Legislature that is has investigated 100 percent of the
reports requiring investigation.
Some CPS reports have not been investigated—Despite a statutory
requirement to investigate 100 percent of the CPS reports it receives and the
importance of doing so to protect children, the Division has failed to investigate some
of the reports it received between July 2002 and March 2005. Auditors’ analysis of
the automated case data for the 91,267 CPS reports received during this period
found that 920 of these reports were missing both the date the investigator
responded to the report as well as the investigation’s results, known as allegation
findings, which raised questions about whether these reports had been investigated.
Statute requires that allegation findings be entered in the Division’s automated case
management system within 21 days of receiving the report. Further, division policy
requires that all documentation on the investigation, including the initial investigation
response date, be completed within 45 days of the investigator’s receiving the report.
Auditors examined the complete case records for a judgmental sample of 15 of the
920 reports and found that 3 had not been investigated by CPS.1 Specifically:
􀁺􇨠 CPS received a report in November 2003 alleging priority 2 sexual abuse of the
alleged perpetrator’s 10-year-old daughter, but there was no evidence of an
investigation occurring.
􀁺􇩃 CPS received a report in June 2004 alleging priority 2 physical abuse of a child
under the age of 2, but there was no evidence of an investigation occurring.
􀁺􇩃 CPS received a report in October 2004 alleging priority 3 physical abuse of a 7-
year-old child, but there was no evidence of an investigation occurring.
Division management has since directed CPS staff to review the remaining reports to
determine whether any additional reports were not investigated. Although the
Division reports that it has completed this review, auditors found problems and
inconsistencies with the review’s conclusions and therefore it cannot be reliably
1 A case record comprises an electronic and hard copy record. The electronic record is maintained in the Division’s
automated case management system and includes information on the Division’s investigative activities, findings, and
decisions. The hard copy record includes documents generated outside the Division, documents that require signatures
from individuals outside the Division, and hard copy forms not maintained electronically.
State of Arizona
page 10
determined how many of these 920 reports were or were not investigated. While the
Division found evidence that some of these reports were investigated, in other
instances the investigations had only occurred within the past few months even
though the reports had been received months or even years earlier. Further, in other
instances, even though the Division indicates that the reports were investigated by
CPS, the case records do not support this assertion. For example:
􀁺􇩉 In July 2004, a law enforcement officer reported to the hotline allegations of
priority 4 neglect involving 2 children. In November 2004, 3-1/2 months after the
report was received, it was assigned to a CPS investigator. However, the
automated case management system does not contain any information
regarding an investigation by CPS. In fact, the only other information in the
system shows that in September 2005, 14 months after the report was received,
finding allegations were entered in the system but they appear to be
placeholders because there is a comment related to the allegation findings that
says “investigation continuing—determination is still being made as to findings.”
Unclear whether other investigations were conducted or thoroughly
completed—For some additional CPS reports, it is unclear whether investigations
were conducted or thoroughly completed because important information is missing
from the automated case management system. For example, auditors’ analysis of
the automated case data for the 91,267 CPS reports received between July 2002 and
March 2005 found another 651 reports that had an initial investigation response date
recorded in the automated case management system, but were still missing any
allegation findings as of July 21, 2005. The recording of allegation findings signifies
that the investigation has been completed and it documents the investigator’s
conclusions. In addition, there were another 76 reports that had allegation findings
recorded in the system for some, but not all, of the allegations. In both examples,
many of the reports were received in fiscal years 2003 and 2004. Auditors also noted
entries in the electronic case records of a few reports where division staff questioned
or could not determine whether there had been an investigation because there was
no information in either the hard copy records or the automated system regarding
what occurred during the investigation.
Division inaccurately reports 100 percent investigation rate—Although
auditors found instances where CPS reports were not investigated and lack of
documentation in the system to support whether other investigations were
conducted or thoroughly completed, the Division has routinely reported in its Child
Welfare Reporting Requirements Semi-annual Report that it has investigated 100
percent of the reports requiring a CPS investigation. The semiannual reports further
note that the Division has maintained this investigation rate since 1998. However, this
rate is based on whether a report is assigned for investigation, not on whether it has
actually been investigated. A more appropriate measure of investigation rate would
be based on the number of CPS reports received that have findings for all allegations
and for which the supervisor has reviewed and approved the findings. This would
Office of the Auditor General
page 11
require a modification to the automated case management system to capture
supervisor approval of each of the allegation findings.
Division has not conducted some investigations and
other actions in a timely manner
Although the Division is statutorily required to conduct prompt investigations, staff
have not consistently met statutory and policy time frames for initiating investigations,
conducting the investigative work, documenting investigative results or allegation
findings, and closing or transferring investigations for ongoing case management. It
is important that these actions occur in a timely manner to ensure the safety of
children, as well as to initiate additional reviews, ensure information is available if a
subsequent report is received on the same family, and for management to monitor
staff workload and productivity.
Division has not initiated some investigations in a timely manner and
does not know when other investigations began—Although the
Department is statutorily required to conduct prompt investigations of child abuse
and neglect to ensure the children’s safety and well-being, it has not initiated some
investigations in a timely manner and does not know when it began some other
investigations. Division policy outlines the time frames within which an investigator
must begin investigating a CPS report. For example, if the report has been classified
as priority 1, the investigator has 2 hours from the time the report is transmitted from
the hotline to the local office to initiate action to determine the safety of the children
involved. Auditors’ analysis of the automated case data for the 91,267 CPS reports
received between July 2002 and March 2005 found that only 49,197, or 54 percent,
had investigations initiated within the outlined time frames; 11,363, or 12 percent,
were not initiated within the outlined time frames; and 30,707, or 34 percent, had
missing or invalid investigation response dates, making it impossible to tell if the
investigations were initiated in a timely manner. As illustrated in Table 4 (see page 13),
of the investigations that were not initiated on time, most were initiated in 5 or fewer
days, but 1,253 investigations, or 11 percent, were started more than 30 days late.
Most of the reports with missing and invalid response dates—approximately
25,000—were due to invalid response dates. Invalid response dates arise when the
response date precedes the date the report was assigned for investigation.
According to division staff, invalid dates may be a result of typographical errors;
recording the date emergency personnel, such as the police, responded to the
situation (rather than the CPS investigator); or the Division’s practice of not recording
in the automated case management system the assignment of a report for
investigation when the family surname is unknown until the investigator has identified
the family. In order for the Division to effectively monitor investigative timeliness, it will
need to address these issues through adding edits to the automated system to
prevent invalid dates being input, clarifying policy to clearly indicate that the CPS
State of Arizona
page 12
investigator’s response time must be recorded in the automated case management
system even if emergency personnel are also involved, and modifying the automated
case management system to allow the recording of a report assignment with an
unknown family surname and then later merge it with any prior cases once the family
surname becomes known.
Division has not always conducted investigation work promptly—Not
only is it important that investigations be initiated in a timely manner, it is also
important that all of the needed investigative work be conducted promptly to ensure
children’s safety and ensure that needed services are provided in a timely manner.
Statute requires that an investigation be completed within 21 days of a report's
receipt. However, auditors noted that the investigations for some of the 920 reports
discussed earlier languished for months or even years after the report was received.
For example:
􀁺􇩉 In January 2003, CPS received a report alleging priority 3 physical abuse of a 5-
year-old child by his father. The report was assigned to an investigator who
initiated an investigation in February 2003 by attempting to contact the child at
school and the family at their home twice during a 10-day period. During both
attempted home visits, the investigator reported knocking on the door several
Office of the Auditor General
page 13
Table 4: Compliance with Initiating Investigations
Within Policy Time Frames
Reports Received from
July 1, 2002 Through March 31, 2005
Total
Priority 1
High Risk
Priority 2
Moderate Risk
Priority 3
Low Risk
Priority 4
Potential Risk
Number of investigations
initiated within policy time
frames
49,197
5,382
14,571
20,952
8,292
Number of investigations
with missing or invalid
response dates
30,707
10,265
9,138
8,796
2,508
Number of investigations
not initiated within policy
time frames1
Delayed 1 day or less 3,185 547 964 1,422 252
Delayed 2 to 5 days 4,185 236 1,389 2,274 286
Delayed 6 to 10 days 1,303 57 387 672 187
Delayed 11 to 20 days 1,018 24 308 554 132
Delayed 21 to 30 days 419 8 136 214 61
Delayed over 30 days 1,253 46 356 657 194
Total 11,363 918 3,540 5,793 1,112
1 The timeliness analysis of initiating report investigations takes into account aggravated and mitigated time frames.
Source: Auditor General staff analysis of data on CPS reports received between July 1, 2002 and March 31, 2005,
maintained on the Department’s Children’s Information Library and Data Source system.
times and leaving her business card. However, no additional investigative work
was performed until September 2005, more than 2-and-1/2 years after the report
was received, when the same investigator contacted several schools and found
out where the child was now attending school. The investigator obtained the
family’s address from the school and conducted a home visit. During the home
visit interview, the parents denied the allegations. A week later, the investigator
interviewed the alleged child victim and his brother at school. Both of them
denied the incident. The investigator subsequently unsubstantiated the
allegation, citing “No evidence of physical abuse or neglect was found to
request proposed to substantiate.”
􀁺􇩏 On January 14 and January 19, 2005, two separate reports were received on the
same family alleging priority 3 physical abuse and priority 2 sexual abuse of the
alleged perpetrators’ 11-year-old adopted daughter. However, no investigative
activities were performed until July 2005, 6 months later, when a CPS unit
supervisor discovered that these reports had never been investigated. The
assigned investigator telephoned the adoptive father and set up an appointment
for a home visit. However, on the date of the scheduled visit, no one was home.
The visit was rescheduled for 2 weeks later, at which time the investigator went
to the home and interviewed the father and child. The investigator
unsubstantiated the allegations the next day, citing “Child was seen and
interviewed on 8/2/05. Child did not disclose abuse or neglect. There is no
evidence to support a substantiated finding. Child appeared healthy and
developmentally on target.”
Division has not always recorded investigation results in a timely
manner—Although investigators are statutorily required to record the investigation
results or allegation findings in the automated case management system within 21
days of receiving a report, investigators have frequently failed to do so. Recording the
allegation findings is important because it indicates that the investigation has been
completed.
It is also important that the allegation findings be entered into the system in a timely
manner for a number of other reasons. First, if an allegation is proposed for
substantiation, it is referred to the Protective Services Review Team within CPS, which
reviews the investigation to ensure it was thorough and the evidence supports the
proposed substantiation. Second, if it is determined that an allegation was
unsubstantiated, CPS must inform the child’s parent(s) or guardian(s) of the
investigation’s outcome if he/she either made the report or was the alleged
perpetrator. Third, if a subsequent CPS report is made on the family or the alleged
perpetrator, the investigator will be able to factor the allegation findings into the
subsequent report. Finally, recording allegation findings allows CPS management to
monitor investigator workload and productivity.
State of Arizona
page 14
However, auditors’ analysis found less than one-half
of the allegation findings were entered into the
system on time. Auditors analyzed the automated
case data for the 193,702 allegations included in
CPS reports received between July 2002 and
March 2005 and found that as of July 21, 2005, a
total of 92,165, or 48 percent, of the allegation
findings were entered into the automated case
management system on time (see Figure 3). Of the
101,537 allegation findings that were not entered
into the system on time, 45,530, or 45 percent, of
the allegation findings were entered a month or
more after the required time frame, and 3,441, or 3
percent, of the allegations were still missing
findings. Therefore, it was not readily apparent
whether those investigations have been
completed.
Division has not always closed or
transferred investigations in a timely
manner—Although division policy requires that
within 45 days of a report’s receipt the investigator
is to either close the case in the system or transfer
it for ongoing case management, investigators
have frequently failed to do so. It is important that
investigations be closed or transferred in a timely
manner because these actions ensure that the
investigation undergoes supervisory review to
make sure it is thorough and complete and that
children and families are promptly receiving any
needed services. Further, failure to close or
transfer investigations in a timely manner results in
an inaccurate picture of the number of active
investigations and hinders management’s ability
to monitor and manage investigator workload and
productivity. However, auditors’ analysis found
that less than one-half of the investigations
initiated from reports received between July 2002
and March 2005 were closed or transferred on
time. As noted in Figure 4, as of July 21, 2005,
37,609, or 41 percent, of the investigations were
closed or transferred on time while 7,368, or 8
percent, were closed or transferred 6 months or
more after the required time frame; and 7,346, or
8 percent, of the investigations still had not been
closed or transferred.
Office of the Auditor General
page 15
Figure 3: Compliance with Entering Allegation Findings
Within 21 Days of Report Receipt
Reports Received from July 1, 2002
Through March 31, 2005
Exceeded by 1
to 7 days—20,993
Exceeded by 8 to
30 days—31,573
Exceeded by 1 to
6 months—38,706
Met
standard—92,165
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and March 31, 2005, maintained on the
Department's Children's Information Library and Data Source system.
Exceeded by over
Exceeded by 6 months 1 year—1,667
to 1 year—5,157 Not entered—3,441
Figure 4: Compliance with Closing or
Transferring Investigations
Within 45 Days of Report Receipt
Reports Received from July 1, 2002
Through March 31, 2005
Exceeded by 6 months
to 1 year—5,202
Not closed—7,346
Exceeded by 1 to
30 days—14,723
Exceeded by 1
to 6 months—24,221
Met
standard—37,609
Source: Auditor General staff analysis of data on CPS reports received
between July 1, 2002 and March 31, 2005, maintained on the
Department's Children's Information Library and Data Source
system.
Exceeded by
over 1 year—2,166
Some investigations not thorough
Although the Division is statutorily required to conduct thorough investigations to
ensure child safety and it has developed policies to help ensure staff meet this
requirement, the Division has not ensured adherence to the policies. Auditors
randomly selected and reviewed the hard copy and electronic records for 30 of the
18,839 CPS reports received between October 1, 2004 and March 31, 2005, and
found four key areas where staff have not consistently followed policies to ensure
thorough investigations. Specifically:
􀁺􇨠 Independent supervisory review of prior reports not always occurring—Although
required by policy, investigators have not always obtained an independent
supervisory review of new CPS reports when three or more prior reports existed.
The intent of this review by supervisory personnel unconnected to the case is to
determine, among other things, whether all allegations in previous reports were
addressed; whether a pattern of cumulative harm to the identified child victim or
any other child residing in the home is evident or emerging; and whether
additional information, such as school records or mental health records, should
be obtained. Eleven of the 30 reports auditors reviewed met the criteria for an
independent review because each had between 3 and 12 prior reports.
However, there was no evidence that an independent review had occurred for
any of these reports. One of the reports that should have undergone an
independent review had 5 prior substantiated reports comprising 25 allegations
of neglect and abuse ranging from priority 1 to priority 4.
􀁺􇨠 Reasonable efforts to locate and contact the child victim and his/her family not
consistently occurring—Although division policy requires investigators to make
reasonable efforts to locate and contact the alleged child victim and his or her
family to ensure the child is safe and assess whether services are needed to
ensure the child’s continued safety, auditors’ review noted 10 instances where
investigative efforts did not appear adequate. The case example in the textbox
(see page 17) illustrates a situation in which insufficient action was taken to
contact the child victims, and as a result, needed services were unnecessarily
delayed.
􀁺􇩃 Child safety assessments not consistently completed or approved as
required—Investigative staff have not always completed a child safety
assessment at the conclusion of an investigation, and even when they were
completed, supervisors had not always reviewed and approved these
documents. Division policy requires that a child safety assessment (CSA) be
conducted as part of every investigation to assess the present and/or
foreseeable danger of serious harm to children in the family and, if appropriate,
State of Arizona
page 16
to develop a safety plan.1 Investigators are required to complete a CSA within
24 hours after first seeing the alleged child victim and at the conclusion of the
investigation; however, auditors found that for 13 of the 30 investigations, there
was no evidence that a CSA was completed at the conclusion of the
investigation, nor any indication why the assessment had not been completed.
Policy also requires supervisors to sign and date the completed hard copy CSA
to indicate their review and approval of the overall assessment and safety plan.
However, auditors found that for 9 of the 30 investigations, supervisors had not
signed and dated the CSA.
􀁺􇩉 Information recorded on system does not consistently reflect investigation
findings—Despite division policy that outlines the criteria for allegation findings,
auditors’ review of 30 hard copy investigative files and associated electronic
case records noted instances where the allegation findings entered into the
automated case management system did not accurately reflect the outcome of
the investigation. For example, in the case example cited above, even though
the three reports appear to validate the allegations of neglect of the younger
child and were proposed for substantiation by the investigator in consultation
with her acting supervisor, they were subsequently modified to unsubstantiated
by another supervisor with no explanation. In another example, the investigator
unsubstantiated priority 2 neglect allegations involving two children even though
she never made contact with the children. The supervisor assigned to the
investigation later told auditors that the findings should have been recorded as
“unable to locate.”
Office of the Auditor General
page 17
Case Example
In March 2005, a CPS report was received citing priority 2 allegations of neglect involving two
children, ages 10 and 17. Although the family had received two prior reports alleging similar
allegations in October and December of 2004, there was no evidence that the case manager who
was assigned to the two prior reports ever contacted the children or did other important investigative
tasks. A month after the second report was received, another case manager was asked to assist the
assigned case manager with the investigation; however, the Division did not ensure that the family
and the victims were contacted. Specifically, the assisting case manager attempted but was unable
to visit the family at its home. Although the assisting case manager was informed by the mother
that he should visit the children at school, he was unavailable to assist with the investigation during
school hours. Further, although the assisting case manager informed the supervisor of this
situation, she did not assign someone else to interview the children. Therefore, it was not until the
third report was received in March 2005 and a different case manager was assigned that a thorough
investigation took place. As a result, the youngest child was removed from his home so that he
could receive medical and clinical treatment for several serious mental health disorders.
Additionally, the following services were provided to the family: out-of-home placement for the
youngest child, psychological evaluations for the youngest child and mother, and parent aide
services and substance abuse treatment for the mother.
1 When conducting a CSA, investigators determine the potential for present or foreseeable danger of serious harm to a child
through assessment of 17 safety factors, such as whether sexual abuse is suspected and whether circumstances suggest
that continued sexual abuse is an immediate concern, or whether drug and/or alcohol use by the caregiver or others living
in or having access to the home places the child in immediate danger.
Investigation documentation not always current, accurate,
or complete
Although division policy requires that the case records be current, accurate, and
complete, auditors identified problems in each of these areas. First and foremost, the
case record information is crucial in assessing and ensuring child safety. It is also
important for other critical functions, such as for after-hours and other staff
addressing urgent situations when the assigned investigator is not available and for
the safety assessment and decision-making process if a subsequent report on a
family is received. Because the appropriateness of decisions made using case data
is contingent on the data’s quality, inaccurate or incomplete information may lead to
poor or dangerous decisions. In addition, current, accurate, and complete case
records are needed for management to adequately monitor staff workload and
productivity.
Despite the importance of documentation, previous audits as well as this one have
identified problems with the case record documentation. For example, a May 2005
performance audit of the Division’s data integrity process found that there were errors
and omissions in the automated system’s data, and 48 percent of the case
management staff responding to an auditor survey reported that data problems
hindered their ability to efficiently and effectively perform their job duties. Further, 13
percent of the case management staff responding to the survey reported that data
problems hindered their ability to ensure child safety and well-being (see Auditor
General Report No. CPS-0501). The Division agreed with this finding and plans to
implement all recommendations. Additionally, although policy requires the electronic
case record to be updated no more than 10 days from the date of the event being
documented, this audit found examples where investigative information was not
recorded until months or even years after the investigation was conducted,
sometimes with questionable accuracy. For example:
􀁺􇨠 In August 2005, 2-and-1/2 years after an initial CPS report was made, a former
CPS supervisor entered information into the system indicating that an
investigation was conducted 2 months after the report was received and that the
alleged physical abuse of the 6-month-old by his father was unsubstantiated
because no bruising was evident. Further, the mother indicated the father had
returned to Texas and she was going to raise the child on her own away from
the father’s violent behavior. According to the supervisor, during this audit she
obtained this information by telephone from the CPS investigator whom this
report had been assigned to (this individual had not worked for the Department
for over 2 years). However, the accuracy of this information is questionable
because the date of the case manager’s visit to the child is recorded in the
system as taking place 2 months after the case manager resigned from the
Department. Auditors subsequently spoke with the former CPS investigator, and
the information he provided leads auditors to further question the accuracy of
the information in the system. Specifically, the former CPS investigator provided
auditors with information that conflicts with the information the supervisor
State of Arizona
page 18
recorded in the case management system. For example, he reported to auditors
that he interviewed the father, but the information in the system noted that the
father had moved to another state and only the mother was interviewed.
Further, in some instances the case record documentation is not complete. For
example, although policy requires at the close of an investigation that the investigator
document a case note narrative in the Division’s automated case management
system that summarizes the progress, events, concerns, and crucial information
related to the investigation, auditors found many examples where this did not occur.
One example involved allegations of neglect and physical abuse of two children
where the family had an ongoing history of alleged abuse and neglect. The closing
summary indicated only that “the case was staffed with a supervisor to discuss the
allegations, it was determined the allegations would be unsubstantiated, and the
case would be approved for closure.” There was no mention of the prior case history,
the basis for the unsubstantiated findings, or whether services had been offered to
and accepted by the family. If prepared properly, closing summaries can be used by
subsequent workers to quickly obtain a comprehensive picture of what occurred
during prior investigations without having to read the entire case record. Therefore,
the Division needs to ensure that investigators include in their investigative
documentation a comprehensive closing summary. One way to improve
documentation may be for the Division to adopt, for state-wide use, the closing
summary template used in districts 3 and 4. The template guides investigators and
ongoing case managers to document information such as the original reason for
service, present whereabouts of the children, progress made in
services/achievement of goals and objectives, justification for case closure, areas
where problems may recur, description of aftercare plan and services, case
manager's assessments of the family, and date and description of the last face-to-face
contact.
Additional actions needed to improve investigative
performance
The Division needs to take additional steps to improve its investigative performance.
The Division attributes its investigation problems primarily to unmanageable
workloads, staff turnover, and the limited experience of some CPS supervisors and
newly hired investigators and continues to address these issues. However, since
these factors are likely to continue, additional meaningful changes are needed,
including streamlining the investigation process and establishing effective oversight
and accountability mechanisms.
Division taking steps to address ongoing barriers hindering
investigative performance—Division personnel attribute many of the
investigation problems to unmanageable workloads, staff turnover, and the limited
experience of some CPS supervisors and newly hired investigators. Between 2002
and 2006, in an effort to ensure manageable workloads, the Division has increased
Office of the Auditor General
page 19
the number of its CPS case management and support staff positions by 551.1
However, according to division management, this has not resolved the workload
issue because of continuing problems with hiring and retaining staff. The Division
reports that as of June 2005, it had 165 case manager positions vacant and an
annualized turnover rate of 19.8 percent.2 Although it also had 163 staff in training to
fill the vacant positions, the program administrator indicated that due to the
complexity of the job, it takes staff a year or more to become experienced and
competent in their jobs, which impacts their ability to manage their workloads. The
quality of supervisory oversight is also being impacted because when vacancies
occur, supervisors are assisting with investigations which, in turn, limits their ability to
supervise the staff in their units. Similar issues were cited in a 1997 performance audit
of the Division’s investigative performance (Auditor General Report No. 97-18).
The Division indicates that it has already implemented or is in the process of
implementing additional steps to address unmanageable workloads and the limited
experience of some of its supervisors. Specifically:
􀁺􇩄 Division implementing strategies for recruiting and retaining staff—The Division
has initiated actions to improve staff recruitment and retention. For example, the
Division is participating in a multi-state, 5-year study to identify effective
strategies for recruiting and retaining quality and experienced case
management staff. As a part of this study, the Division has developed
recruitment and retention strategic plans for two pilot sites, one in Phoenix and
the other in Casa Grande. Some of the plans’ goals include developing local
recruiting plans, modifying the interview process, and providing prospective
candidates a better understanding of case management work using realistic job
videos. If these strategies prove successful, the Division plans to integrate the
project into its division-wide strategic plan.
The Division also continues to use stipends in an effort to recruit and retain case
management staff. For example, the Division has a $1,300-per-year "rural
recruitment and retention" stipend that is available to all CPS specialist IIs and
IIIs, supervisors, and program specialists in the four rural districts as these
individuals are responsible for ensuring the safety and welfare of children in their
communities 24 hours a day, 7 days a week. Similarly classified employees in
districts 1 and 2 do not receive the stipend because these districts have
permanent after-hour investigative teams available to provide 24-hour coverage.
In addition, in 2003 the Department received approval for an investigative
stipend. This stipend equals 10 percent of base pay and is available to
investigative workers with at least 36 months of CPS experience who take on 6
or more CPS reports during the month the reports are received. During fiscal
year 2005, the Division paid an average stipend of $2,306 to its case managers
State of Arizona
page 20
1 The additional positions are funded by General Fund and TANF appropriations and other nonappropriated federal
program monies.
2 Auditors noted some discrepancies in the Division’s reported filled positions, which the Division is working with auditors
to reconcile.
and supervisors, with the actual stipends ranging from $295 to $4,819. Finally,
according to division management, the Department has discussed with its
personnel office the possibility of offering a geographic stipend to attract and
retain staff in some of the “hard-to-staff” rural areas including Yuma, Bullhead
City, Kingman, Prescott Valley, Winslow, and Lake Havasu.
􀁺􇩄 Division implementing supports to help workers manage their workloads—The
Division has also taken action to help investigators manage their workloads. For
example, in April 2004, the Division began implementing a “support response
team” protocol that requires each district to make available one staff person to
assist with investigating CPS reports. If a district falls behind in responding to
investigations, the district e-mails the central office administrator, who will
approve the support team to assist the struggling district for up to 2 weeks.
According to division management, the team has been used three times.
Additionally, because of the vacancies in all the districts, the administrator has
been using central office staff with previous experience in CPS investigations,
supervision, and/or case management to provide assistance to the districts.
The Division is also establishing in-home service units, which it believes should
help reduce the workloads of some investigators. Typically, when an
investigative case is completed and findings have been recorded for all the
allegations, the case will be closed or transferred to an ongoing worker who will
arrange for and monitor the family’s participation in services.1 These ongoing
workers have traditionally managed both in-home and out-of-home cases. While
in-home services cases primarily involve monitoring a family’s voluntary
participation in services, out-of-home cases involve many additional actions
including filing a dependency petition, developing and monitoring a case plan,
and routinely meeting with the child and his or her family and foster caregiver.
According to division personnel, some investigators will retain an in-home
services case in their workload and monitor the family’s participation in services
rather than transfer it to an ongoing case manager they believe already has a
heavy workload. However, once the in-home services units are established, the
completed investigation cases requiring in-home services will be transferred to
these new units. The Division plans to staff the units with the 137 new case
management positions authorized in fiscal year 2006 and plans to have these
units in place in all districts by January 2006.
􀁺􇩄 Division implementing an online reporting tool to enhance reporting and
monitoring—According to the Division, it is implementing a new online
automated case management system reporting tool that will allow
management, supervisors, and CPS staff to view collected data, analyze trends,
and monitor performance. The Division plans to use the reporting tool initially to
report and monitor response times for CPS investigations, timeliness of CPS
investigations, and timeliness of case manager visitations with children and
Office of the Auditor General
page 21
1 The cases retained by investigators are those where the family is receiving services, but no children have been removed
from the home.
families. According to division management, the reporting tool will be
implemented in January 2006.
Although the Division plans to implement the tool to enhance its reporting of
automated case management data and monitoring of related CPS activities,
division management should not underestimate the impact that unreliable data
may have on the Division's ability to effectively implement the tool. In order for
the Division to fully utilize the tool and maximize its effectiveness, the data
maintained in the automated case management system must be timely,
complete, and accurate.
Additional steps needed to improve investigative performance—This
audit found that although the Division has policies and oversight processes that are
designed to help ensure that staff conduct timely and thorough investigations, these
mechanisms are not working as intended. Therefore, the Division needs to focus on
making meaningful changes to these mechanisms. Specifically:
􀁺􇩓 Streamline investigative tasks—The Division needs to significantly streamline the
investigative process. This recommendation is particularly important because it
is likely that the Division will always struggle with recruitment and retention
issues. This recommendation was most recently made in a May 2005
performance audit of CPS’ data integrity process (see Auditor General Report
No. CPS-0501). In that report, it was noted that the Division had established a
workgroup in 2002 to develop recommendations for reducing investigative tasks
while still ensuring children’s safety. However, this workgroup was only of limited
duration, and while it developed recommendations, they were not all
implemented. For example, the workgroup recommended that when law
enforcement involvement is necessary, the hotline worker rather then the CPS
unit should e-mail the police version of the CPS report directly to law
enforcement after sending the report to the responsible CPS investigative unit.
Further, the workgroup did not perform a comprehensive review of all the
processes impacting the investigations area and focused only on those
processes implemented state-wide, even though each district may develop
additional processes that take into account factors unique to them. Therefore,
the audit report recommended that the Division conduct a comprehensive and
systematic review of its processes to identify those that can be streamlined or
eliminated.
􀁺􇩉 Increase accountability—Division administration needs to determine its top
priorities for the investigative function and hold staff accountable for achieving
them. Specifically, the Division needs to identify the top three to five areas that
are most important to the investigative process and then focus on those areas.
Examples of potential priorities could include 1) investigating all CPS reports, 2)
conducting investigations according to statutory and policy requirements, 3)
documenting investigative activities completely and accurately, and 4) providing
required supervisory oversight.
State of Arizona
page 22
Division administration also needs to better use management reports to monitor
performance in these critical areas. While the Division has monthly exception
reports on issues such as reports missing allegation findings, as found in the
May 2005 CPS performance audit and this audit, the reports are not being
effectively used to resolve the exceptions. Also, although the six districts have
developed monitoring mechanisms, they are varied in terms of what and how
information is being tracked, and therefore, are of limited value to department
and division administration for tracking overall performance and targeting
problem areas. Therefore, the Division should revise or develop additional
management reports that will better allow administration to routinely assess
performance in critical areas, both overall and at targeted levels such as offices
or units. However, for these reports to be of value, the Division will need to
ensure the underlying data is accurate and complete.
Finally, division administration needs to establish accountability at all staff levels
for making sure the priorities are achieved. While the Division has a process for
evaluating staff performance against expected standards using annual written
evaluations, it appears that the evaluations are not always being conducted.
This may be partly because there is no central mechanism for tracking when
performance evaluations are due or performed. Department personnel
recognize the lack of a centralized mechanism as a barrier to ensuring that staff
evaluations are performed in a timely manner. However, it is left up to a worker’s
immediate supervisor to monitor this information. Auditors reviewed ten
personnel files and found that five were missing one or more required
evaluations. To ensure employees are held accountable for achieving the
Division’s priorities and expectations, the Division’s personnel unit should
implement a centralized tracking system to make certain staff receive their
required annual evaluation. Further, this tracking system should also record
each staff person’s overall performance rating for the year so that management
can readily identify those workers in need of corrective action.
􀁺􇩃 Communicate importance of documentation—Division management should
communicate to its employees the importance of recording timely, accurate,
and complete documentation in the automated case management system to
help ensure child safety and well-being. Management philosophy has a
significant influence on the Division’s operations and because of workload
concerns, management has notified case management staff that documenting
information is a secondary priority to ensuring child safety. However, the Division
should not overlook the negative impact that incomplete and untimely
documentation can have on a child’s continued safety and well-being, as well
as the investigator’s ability to investigate CPS reports and substantiate
allegations of abuse and neglect where appropriate.
Office of the Auditor General
page 23
Recommendations:
1. To ensure the Division‘s reported investigation rate accurately reflects
investigated reports, the Division should base the rate on the number of CPS
reports received that have findings for all allegations and for which the
supervisor has reviewed and approved the findings. This will require a
modification to the automated case management system to capture supervisor
approval of each of the allegation findings.
2. To ensure the Division can effectively monitor investigation timeliness, it needs
to take the following actions to better ensure accurate data on initial response
time:
a. Add edits to the automated case management system to prevent invalid
dates being input.
b. Clarify policy to clearly indicate that it is the CPS investigator’s response
time that must be recorded in the automated case management system,
even if emergency personnel are also involved.
c. Modify the automated case management system to allow the recording of
the assignment of a report with an unknown family surname and then later
merge it with any prior cases once the family surname becomes known.
3. To better ensure the safety and well-being of child victims of abuse and neglect,
the Division should investigate 100 percent of reports requiring CPS
investigation.
4. To improve the usefulness of the investigation closing summary documentation,
the Division should ensure that investigators document consistent and
comprehensive information.
5. To better ensure investigative performance is timely and thorough, the Division
should:
a. Establish three to five priorities that are most important to the investigative
function and would demonstrate that the Division is performing efficiently
and focus on these areas.
b. Develop and use additional management reports or other mechanisms to
keep division administration apprised of investigative performance in the
established priority areas so that timely corrective action can be taken if
needed.
State of Arizona
page 24
c. Hold staff accountable for achieving the Division’s priorities and
expectations by requiring the Division’s personnel unit to implement a
centralized tracking system to record when staff evaluations are due and
conducted and each person’s overall performance rating so that
management can readily identify those workers in need of corrective action.
6. Because of the negative impact that untimely, inaccurate, and incomplete
documentation can have on a child’s continued safety and well-being, as well
as an investigator’s ability to investigate CPS reports and substantiate
allegations of abuse and neglect where appropriate, division management
should communicate to staff the importance of recording timely, accurate, and
complete documentation in the automated case management system.
Office of the Auditor General
page 25
State of Arizona
page 26
Office of the Auditor General
page a-i
APPENDIX
State of Arizona
Office of the Auditor General
page a-iii
Appendix: Child Abuse Hotline Report Priority Classification System
Priority 1 High Risk
Response times:
• Standard within 2 hrs
• Mitigated within 24 hrs
Priority 2 Moderate Risk
Response times:
• Aggravated within 24 hrs
• Standard within 48 hrs
• Mitigated within 72 hrs
Priority 3 Low Risk
Response times:
• Aggravated within 48 hrs
• Standard within 72 hrs
• Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4 Potential Risk
Response times:
• Aggravated within 72 hrs
(excluding weekends and
holidays)
• Standard within 7 consecutive
days
Physical abuse:
Child death due to physical abuse
or neglect or suspicious death;
injuries requiring emergency
medical treatment; child under the
age of 6 observed or reported to be
struck in the head, face, neck,
genitals, or abdomen which could
likely cause injury; child under the
age of 24 months is shaken;
physical abuse by a parent,
guardian, or custodian who has a
previous substantiated priority 1
report or who threatens or presents
serious bodily harm to the child
now.
Physical abuse:
Injuries that may require medical
treatment; priority 3 injury to a child
under the age of 6; child 6 years of
age or older observed or reported
to be struck in the head, face,
neck, genitals, or abdomen which
could likely cause injury; parent,
guardian, or custodian presents
serious bodily harm to a child or
fears or threatens to harm child if
no intervention is received and he
or she has a previous
substantiated report of physical
abuse; child under 3 months of age
born to parents whose parental
rights have been previously
terminated.
Physical abuse:
Injuries not requiring medical
treatment such as cigarette burns,
single or small bruises, or injury to
buttocks or scalp; parent, guardian,
or custodian fears or threatens to
harm child if no intervention is
received.
Physical abuse:
Home environment stressors place
child at risk of physical abuse
which may include domestic
violence, mental illness, substance
abuse, history of physical abuse
with no current injuries, etc.
Sexual abuse:
Physical evidence of sexual abuse
reported by a medical doctor or
child reporting sexual abuse within
the past 7 days; child reporting
vaginal or anal penetration or oral
sexual contact within past 72 hours
and has not been examined by a
medical doctor.
Sexual abuse:
Sexual behavior within the past 8
to 14 days; attempted sexual
behavior or sexual behavior when
last occurrence is unknown or
when last occurred beyond 14
days and up to 1 year; parent,
guardian or custodian suggests or
entices a child to engage in sexual
behavior, but there is no actual
touching; child is exhibiting
physical or behavioral indicators
which are consistent with sexual
abuse and there are indicators the
behavior is caused by a parent,
guardian or caretaker; child is living
in the home with a person
convicted or a sexual offense
against a child.
Sexual abuse:
Parent guardian or custodian
sexually abused a child in the past
and is now living in a home with a
child; attempted sexual behavior or
sexual behavior when last
occurrence was beyond one year
and the perpetrator currently has
access to the child.
Sexual abuse:
NA
Emotional abuse:
NA
Emotional abuse:
Child diagnosed by a qualified
mental health professional as
exhibiting severe anxiety,
depression, withdrawal or
untoward aggressive behavior,
which could be due to serious
emotional damage by a parent,
guardian or custodian.
Emotional abuse:
Parent, guardian, or custodian
demonstrates behavior or child
reports parent, guardian or
custodian behavior which is likely
to have the effect of fear, rejection,
isolation, humiliation or
debasement of a child.
Emotional abuse:
NA
State of Arizona
page a-iv
Appendix: (Concluded)
Priority 1 High Risk
Response times:
• Standard within 2 hrs
• Mitigated within 24 hrs
Priority 2 Moderate Risk
Response times:
• Aggravated within 24 hrs
• Standard within 48 hrs
• Mitigated within 72 hrs
Priority 3 Low Risk
Response times:
• Aggravated within 48 hrs
• Standard within 72 hrs
• Mitigated within 72 hrs
(excluding weekends and
holidays)
Priority 4 Potential Risk
Response times:
• Aggravated within 72 hrs
(including weekends and
holidays)
• Standard within 7 consecutive
days
Neglect:
Delayed or untreated medical
condition which is life-threatening
or permanently disabling; child of
any age who is left alone and
cannot care for self or for other
children due to physical, emotional,
or mental instability; child under the
age of 6 who is alone now; child 6
to 9 years of age is alone for 3
hours or longer or unknown when
parent, guardian or custodian will
return; imminent harm to child
under the age of 6 due to
inadequate supervision by parent,
guardian or custodian; neglect
results in serious physical injury or
illness requiring emergency
medical treatment; imminent harm
to child due to health or safety
hazards in living environment; child
assessed as suicidal by qualified
mental health professional and
parent, guardian or custodian is
unwilling to secure needed
emergency medical treatment; no
parent willing to provide immediate
care for a child and child is with
caregiver who is unable or
unwilling to care for the child now
or child is left to his or her own
resources; history of extensive
gestational substance abuse to
child under 3 months of age or
mother or child tests positive for
non-prescribed or illegal drug or
alcohol at time of birth; child under
2 months of age displays non-prescribed
or illegal drug or alcohol
withdrawal symptoms; mother is
using cocaine, heroin,
methamphetamines or PCP and is
breastfeeding a child.
Neglect:
Child age 11 to 13 years caring for
a child age 6 or younger for 12
hours or longer; living environment
presents health or safety hazards
to a child under the age of 6 which
may include human/animal feces,
undisposed garbage, exposed
wiring, access to dangerous
objects or harmful substances,
etc.; sexual conduct or physical
injury occurs between children due
to inadequate supervision or
encouragement by parent,
guardian or custodian; no parent
willing to care for a child and child
is with a caregiver who is unable or
unwilling to continue caring for the
child less than 1 week; child under
3 months of age born to parents
whose parental rights have been
previously terminated.
Neglect:
Delayed or untreated medical
problem caused child pain or
debilitation that is not life-threatening
and parent, guardian,
or custodian is unwilling to secure
medical treatment; child under the
age of 9 who is not alone at the
time of the report, but has been left
alone within the past 14 days;
parent, guardian or custodian
demonstrates an inability to care
for a child within the past 30 days
including leaving a child with
inappropriate or inadequate
caregivers; living environment
presents health or safety hazards
to a child 6 years of age or older
which may include human/animal
feces, undisposed garbage,
exposed wiring, access to
dangerous objects or harmful
substances, etc.; food not provided
and child is chronically hungry;
significant developmental delays
due to neglect; parent, guardian or
custodian is not protecting a child
from a person who does not live in
the home and who abused a child;
no parent willing to care for a child
and child is with a caregiver who is
unable or unwilling to continue
caring for the child beyond 1 week
up to 30 days; use of a child by a
parent, guardian or custodian for
material gain which may include
forcing the child to panhandle,
steal or perform other illegal
activities.
Neglect:
Parent, guardian, or custodian has
no resources to provide for child’s
needs including supervision, food,
clothing, shelter and medical care;
home environment stressors place
child at risk of neglect which may
include mental illness, substance
abuse, etc.; living environment is
likely to present a health or safety
hazard to a child; child adjudicated
dependent due to a finding of
incompetency or not restorable to
competency; sexual conduct or
physical injury between children
and unknown if parent, guardian or
custodian will protect; complaint by
law enforcement or officer of
juvenile court alleging dependency
due to a delinquent or incorrigible
act committed by a child under the
age of 8.
•
Office of the Auditor General
AGENCY RESPONSE
State of Arizona
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
1717 W. Jefferson • P.O. Box 6123 • Phoenix, AZ 85005
Janet Napolitano
Governor
David A. Berns
Director
December 14, 2005
Debbie Davenport
Auditor General
Office of the Auditor General
2910 North 44 Street, Suite 410
Phoenix, Arizona 85018
Dear Ms. Davenport:
The Department of Economic Security is pleased to provide the following comments to
supplement the CPS Investigations Performance Audit conducted by your office.
The rights of children to remain safe and in the care of their parents are among the
most fundamental. Child Protective Services protects children by investigating
allegations of abuse and neglect, promoting the well-being of children in permanent
homes, and coordinating services to strengthen families. The Department takes its
mission seriously and appreciates the work of your office in identifying areas of
practice requiring improvement, including investigation response time and timely date
entry into the case management information system.
The Audit conducted by your office covers a thirty-three month time period, specifically
from July 1, 2002 through March 31, 2005. During this almost three year period, our
Department’s Child Protective Services (CPS) received 91,267 CPS reports and
assigned one hundred percent (91,267) of these reports for investigation. As you have
acknowledged in your report, there has been a 27 percent increase in the number of
reports received and assigned for investigation by CPS (from 29,290 reports in 2003
to 37,170 reports in 2005).
Your office reviewed a computer report that identified cases in the database that were
missing two data elements: CPS response time and after investigation findings. Of
the 91,267 reports assigned during this period, you found 920 CPS reports, (1 percent
of the total number of CPS reports reviewed) that were missing these two data
elements. This missing information in the computer system raises questions as to
whether investigations had occurred for those reports. Your office selected 15 of
those reports, reviewed additional electronic and paper records, and found that 3 of
the 15 reports had not been investigated.
Debbie Davenport
Page 2
To ensure child safety, the Division reviewed the electronic and paper files of all 920
reports and determined that of the 920, an additional eight (8) reports had not been
investigated. Investigators were immediately instructed to locate the families involved
and complete safety and risk assessments of the children. In all but one case,
investigators were able to locate the families and take steps to ensure the children’s
safety. In the remaining case, the child had turned 18 since the report had been
received.
This Audit reinforced for the Department the findings of your office’s recent report
issued in May 2005, CHILDS Data Integrity Process, which identified the need for
more timely CPS data entry into the case management information system. The
Department is aggressively pursuing strategies to improve timely data entry, including
continual modification of the case management information system to make it more
efficient and easier to use and the implementation of a Business Intelligence
Dashboard which allows management, supervisors and CPS staff to view collected
data, analyze trends, and most importantly, monitor performance. CPS has prioritized
the following for the initial data display for this new automated tool: response time for
CPS investigations, timeliness of CPS investigations, and timeliness for case manager
visitation with children and families.
The Audit also found that many CPS reports were not responded to within the
timeframes established by our child welfare policy. Our policy was established to
assist CPS supervisors and workers in prioritizing their response to all the CPS
reports that have been assigned for investigation. Based upon additional information
obtained by CPS, such as from the reporting source, hospital personnel, or law
enforcement, CPS may determine that the child is safe and prioritize another CPS
report for response, when the safety of that alleged child victim is unknown. This may
result in an investigation being considered untimely according to our policy, but better
ensures that children are safe.
CPS workers are committed to providing timely and quality investigations. The
increased number of CPS reports that have been assigned for investigation over the
past several years have impacted investigation timeliness and data integrity. In
addition, staff turnover and vacancies have increased caseloads in some offices of the
state. The Department is working diligently to implement strategies to improve the
recruitment and retention of CPS staff, including participation in the Western Region
Recruitment and Retention project headed by the University of Denver.
Debbie Davenport
Page 3
I have also directed CPS to review our:
• Quality Assurance processes to ensure that the CPS investigation process,
including timeliness of initiating investigations, completion of after-investigation
findings, and thoroughness of investigation, are reviewed and
assessed on an ongoing basis.
• District tools used to monitor investigation status to ensure all areas of key
activity are being captured until all elements can be tracked automatically in
the Business Intelligence Dashboard.
We are committed to continued practice improvements, particularly as to data
integrity, retention of CPS staff and supervisors, and the quality and availability of CPS
training. All of these efforts will improve our investigation practice and documentation
of those investigations in the case management information system.
We are providing an attachment which addresses our plans for implementing the
recommendations suggested by your office. Please feel free to contact me at (602)
542-5678, or Tracy Wareing, Acting Deputy Director, Division of Children, Youth and
Families, at (602) 542-3598.
Sincerely,
David A. Berns
David A. Berns
Attachment
DES Response to Auditor General’s Report
CPS Investigations
1
DEPARTMENT OF ECONOMIC SECURITY
RESPONSE TO AUDITOR GENERAL’S REPORT
CHILD PROTECTIVE SERVICES PERFORMANCE AUDIT
DECEMBER 14, 2005
The Department of Economic Security (Department) is providing the following comments and responses
to the finding and recommendations of the Office of the Auditor General’s performance audit of
Division of Children, Youth and Families’ (Division) Child Protective Services (CPS) Investigations.
The rights of children to remain safe and in the care of their parents are among the most fundamental.
Child Protective Services protects children by investigating allegations of abuse and neglect, promoting
the well-being of children in permanent homes, and coordinating services to strengthen families. The
Department takes its mission seriously and appreciates the work of the Auditor General in identifying
areas of practice requiring improvement, including investigation response time and timely date entry
into the case management information system.
Because audits may guide public policy discussions and decisions, it is important to understand the full
context of the total number of CPS reports that were received and assigned for investigation during this
review period. The Auditor General conducted an audit that covers a thirty-three month time period,
specifically from July 1, 2002 through March 31, 2005. During this almost three year period, CPS
received 91,267 CPS reports and assigned one hundred percent (91,267) of these reports for
investigation. CPS was able to complete investigations on over 99.99 percent of these assigned 91,267
reports. As the Auditor General acknowledged, there has been a 27 percent increase in the number of
reports received and assigned for investigation by CPS (from 29,290 reports in 2003 to 37,170 reports in
2005).
The Auditor General reviewed a computer report that identified cases in the database that were missing
two data elements: CPS response time and after investigation findings. The Auditor General found 920
CPS reports, 1 percent of the total number of CPS reports reviewed, that were missing these two data
elements and questioned whether investigations had occurred for those reports. Based upon that finding,
the Auditor General selected 15 of those reports, reviewed additional electronic and paper records, and
found that 3 of the 15 reports had not been investigated.
To ensure child safety, the Division reviewed the electronic and paper files of all 920 reports and
determined that of the 920, an additional eight (8) reports had not been investigated. Investigators were
immediately instructed to locate the families involved and complete safety and risk assessments of the
children. In all but one case, investigators were able to locate the families and take steps to ensure the
children’s safety. In the remaining case, the child had turned 18 since the report had been received.
The Auditor General notes that the Division does not always initiate investigations within the required
timeframes. These timeframes were established to assist CPS supervisors and workers in prioritizing
CPS reports received and assigned for investigation. The Auditor General found that 54 percent of the
CPS investigations were responded to within the required timeframes and 12 percent were not responded
to within the required timeframes. The timeliness of the response in the remaining 34 percent of cases
could not be determined, although investigations were completed in all those cases. For the cases that
were not responded to within the required timeframes, 6,905 or 61 percent were identified as potential or
low risk reports; 3,185 or 28 percent missed the timeliness standard by one day or less and an additional
4,185 or 37 percent missed the timeliness standard by 2 to 5 days.
DES Response to Auditor General’s Report
CPS Investigations
2
The Division’s paramount concern is child safety. CPS supervisors and workers prioritize the order in
which CPS reports will be responded to from the information received from the statewide hotline and
information about the child’s immediate safety received from a variety of sources contacted after the
report is received. These include, but are not limited to; the reporting source, which may provide
additional information; the hospital, to determine a discharge date for a child that is hospitalized; and,
when law enforcement has made the initial response, the officers responding that have information about
the child’s safety. Although these steps help to ensure child safety, these contacts are not considered the
initial CPS response according to the Division’s child welfare policy and its database system. If the
child is determined safe, these initial actions allow CPS to prioritize other investigations that have been
assigned, ones in which child safety cannot be determined through additional contact with others.
Many of the findings in this most recent Auditor General’s report mirror findings in the Auditor’s May
2005 report on the CHILDS Data Integrity Process. CPS staff are committed to providing timely and
quality investigations. The increased number of CPS reports that are assigned for investigation impact
investigation timeliness and data integrity. To address the issues raised in the May 2005 audit, the
Department has committed to making practice improvements and increasing data integrity. In addition,
the Department is pursuing strategies to improve the recruitment and retention of CPS supervisors and
workers, and to increasing the quality and availability of CPS training. All of these efforts will improve
CPS investigation practice and documentation of those investigations in the case management
information system.
One example of these solutions, which will be implemented in January 2006, is the statewide use of a
user-friendly on-line reporting tool (Business Intelligence Dashboard) which allows management,
supervisors and CPS staff to view collected data, analyze trends, and most importantly, monitor
performance from the statewide level down to the worker level The Division has prioritized the
following for the initial data display for this new automated tool: response time for CPS investigations,
timeliness of CPS investigations, and timeliness for case manager visitation with children and families.
Additional data elements will be added after full implementation of this reporting tool.
The Department’s specific response to the Auditor General’s finding and recommendations follow in the
next section.
DES Response to Auditor General’s Report
CPS Investigations
3
RESPONSE TO REPORT FINDING
AND RECOMMENDATIONS
The Department’s response to the Auditor General finding and recommendations includes strategies that
the Division is currently implementing or will begin implementing. Many of these strategies include
modifications to the Division’s case management information system. The Division will begin
immediately to pursue the numerous steps necessary to modify an automated system. These
modifications will be made on an aggressive schedule in order to implement the agreed upon
recommendations of the Auditor General.
Recommendation 1:
To ensure the Division’s reported investigation rate accurately reflects investigated reports, the Division
should base the rate on the number of CPS reports received that have findings for all allegations and for
which the supervisor has reviewed and approved the findings. This will require a modification to the
automated case management system to capture supervisor approval of each of the allegation findings.
DES Response 1:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
The Division currently reports on the number of communications that meet the criteria of a report and
the number of those reports which have been dispositioned (assigned to a case worker) for investigation.
The Division will modify the report to include the number of investigations that have been closed. The
Division will modify the investigation closure process to require that all the findings of allegations of
abuse or neglect be entered into the automated system before the supervisor can approve the closure of
the investigation.
Target Completion Date: March 31, 2006
Recommendation 2a:
To ensure the Division can effectively monitor investigation timeliness, it needs to add edits to the case
management system to prevent invalid dates being input.
DES Response 2a:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will modify the automated system to ensure the following:
1) The response date cannot precede the communication received date.
2) The investigation cannot be closed unless a response date has been entered.
Target Completion Date: June 30, 2006
DES Response to Auditor General’s Report
CPS Investigations
4
In addition, the Division will research what potential modifications can be made to the automated case
management system to allow an “unknown” report to be assigned within the automated system and then
later merged with a prior case when the names of family members become known. Currently,
“unknown” CPS reports are assigned to the CPS worker who initiates the investigation but the CPS
report is not assigned in the case management information system until the surname of the family
becomes known. This prevents the creation of additional cases on the same family in the case
management information system that are not linked to one another. However, this results in invalid
dates in the case management information system.
Target Completion Date for Research: February 28, 2006
Recommendation 2b:
To ensure the Division can effectively monitor investigation timeliness, it needs to clarify policy to
clearly indicate that it is the CPS investigator’s response time that must be recorded in the automated
case management system, even if emergency personnel are also involved.
DES Response 2b:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
DES agrees that it is the CPS investigator’s response time that must be recorded in the automated case
management system. In addition, DES believes that it is also important to document when emergency
personnel have provided first response and have ensured child safety.
The Division will clarify with CPS staff the policy when they can indicate someone other than CPS
conducted the initial response and the subsequent time frame for CPS to initiate their investigation
Target Completion Date: December 31, 2005
In addition, the Division will modify the automated case management information system to allow entry
of both the initial CPS response time and the initial response time of emergency personnel, when
emergency personnel response has ensured child safety.
Target Completion Date: June 30, 2006
Recommendation 2c:
To ensure the Division can effectively monitor investigation timeliness, it needs to modify the
automated case management system to allow the recording of the assignment of a report with an
unknown family surname and then later merge it with any prior cases once the family surname becomes
known.
DES Response to Auditor General’s Report
CPS Investigations
5
DES Response 2c:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will research what potential modifications can be made to the automated case management
system to allow an “unknown” report to be assigned within the automated system and then later merged
with a prior case when the names of family members become known. Currently, “unknown” CPS
reports are assigned to the CPS worker who initiates the investigation but the CPS report is not assigned
in the case management information system until the surname of the family becomes known. This
prevents the creation of additional cases on the same family in the case management information system
that are not linked to one another. However, this results in invalid dates in the case management
information system.
Target Completion Date for Research: February 28, 2006
Recommendation 3:
To better ensure the safety and well being of child victims of abuse and neglect, the Division should
investigate 100 percent of reports requiring investigation.
DES Response 3:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Recommendation 4:
To improve the usefulness of the investigation closing summary documentation, the Division should
ensure investigators document consistent and comprehensive information.
DES Response 4:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will incorporate the CPS supervisor’s review of this requirement through the development
and implementation of an “investigation case closure” template. This template will contain all the
necessary elements the CPS supervisor needs to review prior to investigation case closure, including
documentation of consistent and comprehensive information.
Target Completion Date for Template Implementation: January 31, 2006
Recommendation 5a:
To better ensure investigative performance is timely and thorough, the Division should establish three to
five priorities that are most important to the investigative function and would demonstrate that the
Division is performing efficiently and focus on these areas.
DES Response to Auditor General’s Report
CPS Investigations
6
DES Response 5a:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
Based up the Auditor General’s recommendation, the Division established and set the following
priorities: Response Timeliness, Investigation Completion, and Documentation.
The first two priorities are key performance indicators that are in the Business Intelligence Dashboard.
The Business Intelligence Dashboard will record an investigation as completed when all the allegation
findings are entered. The third priority, documentation, is addressed within the Division’s response to
the Auditor General’s number 4 recommendation.
Target Completion Date: January 31, 2006
The Division will continue to look for opportunities to better ensure timely and thorough investigations.
Recommendation 5b:
To better ensure investigative performance is timely and thorough, the Division should develop and use
additional management reports or other mechanisms to keep Division administration apprised of
investigative performance in the established priority areas so that timely corrective action can be taken if
needed.
DES Response 5b:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division has taken the following steps to improve the development and use of management tools to
monitor performance:
• The Division is implementing a user-friendly on-line reporting tool (Business Intelligence
Dashboard) which will allow management, supervisors and CPS staff to view collected data, analyze
trends, and most importantly, monitor performance. The Division has prioritized the following for
the initial data components for this new automated tool: response time for CPS investigations,
timeliness of CPS investigations, and timeliness for case manager visitation with children and
families. This new tool will be available in January 2006, and will portray data on a statewide,
district, unit, and individual worker basis.
• In October 2005, the Division initiated monthly learning sessions with the Practice Improvement
Specialists (including Central Office and District staff), District Automation Liaisons (DALs),
Division Reports & Statistics staff, the Program Administrator for Finance and Business Operations,
and the District Program Managers to train staff on the use of data. The initial training was provided
by the National Resource Center for Child Welfare Data and Technology and the National Resource
Center for Organization Improvement on October 6th & 7th. The focus of the first learning session
was to develop a baseline of knowledge and understanding around child welfare data. The second
session occurred on November 16, 2005 and focused on some of the current reports which are
DES Response to Auditor General’s Report
CPS Investigations
7
distributed to the Districts, including exception reports. One of the goals of these sessions is to
develop the knowledge and expertise of the staff whose responsibility it is to use data and
management reports to inform and monitor practice.
• Case Reviews are completed on a random sample of cases in each district to monitor performance
based upon the federal Child and Family Service Review. This review includes timeliness of
investigations and other critical functions. After each district review, the findings are reviewed with
Division and District staff. The Case Review mirrors the federal Child and Family Service
Performance measures and identifies the percentage of investigations initiated within state policy
timeframes. These reviews have not identified any uninvestigated reports.
The Division will continue to implement the above strategies and look for other opportunities to monitor
CPS performance.
Recommendation 5c:
To better ensure investigative performance is timely and thorough, the Division should hold staff
accountable for achieving the Division’s priorities and expectation by requiring the Division’s personnel
unit to implement a centralized tracking system to record when staff evaluations are due and conducted
and each person’s overall performance rating so that management can readily identify those workers in
need of corrective action.
DES Response 5c:
The finding of the Auditor General is agreed to and a different method of dealing with the finding will
be implemented.
DES concurs that the timely completion of performance evaluations (ESTEEM) for staff is a critical
component of management. Unfortunately, there is no automated system that can generate reports to
identify which staff have past due ESTEEMs or which staff have upcoming ESTEEMs. DES is working
with the Department of Administration (ADOA) to determine if it is possible to establish an interface
between the ADOA Human Resource Information System (HRIS) and the DES Financial Management
Control System (FMCS) Data Warehouse to generate these reports. DES understands that ADOA is
also exploring an automated tracking system for PASE which is the staff evaluation format being used
by ADOA and most other state agencies. If that evaluation process can be automated more easily and
quickly than developing an interface for HRIS and FMCS, DES would prefer to change to the PASE
evaluation process, rather than developing a duplicate staff evaluation tracking system.
Recommendation 6:
Because of the negative impact that untimely, inaccurate, and incomplete documentation can have on a
child’s continued safety and well-being, as well as an investigator’s ability to investigate CPS reports
and substantiate allegations of abuse and neglect where appropriate, Division management should
communicate the importance of recording timely, accurate, and complete documentation in the
automated case management system.
DES Response to Auditor General’s Report
CPS Investigations
8
DES Response 6:
The finding of the Auditor General is agreed to and the audit recommendation will be implemented.
The Division will continue to communicate the importance of accurate and timely case documentation.
During initial case manager core training, accurate and timely case documentation is trained and the
importance emphasized.
The Division will send a reminder to CPS staff regarding the importance of recording timely, accurate,
and complete documentation in the automated case management system.
Target Completion Date: December 16, 2005
The Division will develop and distribute documentation guides for CPS supervisors and workers.
Target Completion Date: February 15, 2006
The Division will develop and implement an advanced training class on documentation. All CPS
supervisors and workers will be required to attend this training.
Target Completion Date Curriculum Development: February 28, 2006
_______________________________________________
CPS Performance Audits and Information Briefs Issued
Future CPS Performance Audits
Training
Future CPS Information Briefs
Types of Federal Monies Available
CPS Performance Audits
CPS-0501 CHILDS Data
Integrity Process
Information Briefs
IB-0401 Federal IV-E Waiver Demonstration
Project Proposal
IB-0501 Family Foster
Homes and Placements
IB-0502 Revenue Maximization